PM R 7 (2015) 435-442
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Point/Counterpoint
Guest Discussants: Jonathan T. Finnoff, DO, John G. Costouros, MD Feature Editor: David J. Kennedy, MD
Is Ultrasound Guidance Needed for Shoulder Injections? CASE SCENARIO MJ is a 44-year-old teacher who has had right lateral shoulder pain for 5 weeks. The pain developed acutely after he played a pickup game of basketball. He initially presented to his primary care physician, who suspected an acute rotator cuff injury and prescribed naproxen, 500 mg twice daily, along with physical therapy. MJ has completed 4 weeks of appropriate therapy focusing on scapular retraction exercise, pectoralis stretching, and rotator cuff strengthening. He experienced no relief from the therapy or medication, so his primary care physician obtained a shoulder magnetic resonance (MR) arthrogram, which demonstrated thickening of the subacromial-subdeltoid bursa, suggestive of bursitis, and a type I superior labral anterior to posterior (SLAP) lesion. MJ was sent to you for further evaluation and treatment. He currently has a 7 out of 10 level of pain over the anterolateral shoulder that is worse when he performs overhead maneuvers and sleeps on his right side. Upon physical examination he has no tenderness to palpation but experiences pain during active range of motion testing, particularly with internal rotation and abduction, respectively. He also has a positive Hawkins-Kennedy test, Neer sign, and O’Brien test. He has difficulty deciding whether his characteristic pain is reproduced more by the impingement maneuvers or labral maneuver. Neurovascularly, he is intact. You discuss treatment options, and given the failure of conservative treatments thus far, he wishes to pursue a corticosteroid injection in the subacromial bursa. He recently saw a commercial on TV featuring an injection that was performed with ultrasound guidance and asks if ultrasound guidance should be used to perform his injection. Dr Jonathan Finnoff will argue that ultrasound guidance should be used for the injection, and Dr John Costouros will argue that ultrasound guidance is not needed. Jonathan T. Finnoff, DO This scenario is not uncommon. Several important factors must be considered when determining what to do next. First, because several commonly used treatments have failed, one needs to consider whether the working diagnosis is correct. In this case, the patient’s physical examination and MR arthrogram suggest 2 possible causes for the pain, namely subacromial-subdeltoid bursopathy or labral disease. However, it is not known whether one or both of these conditions are responsible for this patient’s pain. It is well known that many shoulder physical examination maneuvers have limited sensitivity and specificity. A recent meta-analysis found the pooled sensitivity and specificity for the Neer sign to be 72% and 60%, respectively, and the sensitivity and specificity of the Hawkins-Kennedy test was 79% and 59%, respectively [1]. Another systematic review concluded that
physical examination tests for SLAP tears were invalid and of limited clinical value [2]. Furthermore, multiple studies have established that patients can have pathologic findings on magnetic resonance imaging (MRI) with no associated symptoms [3-5]. Therefore, based on the available information, it can be concluded that the mechanism generating the patient’s pain is not known with any type of surety. Because the treatment for labral disease is very different from that for subacromial-subdeltoid bursopathy, the first thing that needs to be done is to determine what is causing the patient’s pain. One way to determine what is causing the patient’s pain is to perform diagnostic injections. A diagnostic injection involves guiding a needle to a specific structure and injecting a local anesthetic into the structure (in the case of a joint or bursa) or around the structure
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(in the case of a nerve). If the patient’s symptoms are relieved for the duration of the local anesthetic, it can be concluded that the structure that was anesthetized during the procedure is generating the pain. However, the ability to gain diagnostic information from an injection is predicated upon placing the medication in a specific location. In other words, the injection needs to be accurate or it doesn’t provide any diagnostic information. Ten studies with level 1 or 2 evidence have been performed to evaluate the accuracy of landmark-guided (LMG) subacromial-subdeltoid bursa injections and have concluded that the mean accuracy is 80% [6-15]. Authors of a study with level 1 evidence reported that the accuracy of ultrasound-guided (USG) subacromialsubdeltoid bursa injections was 100% [12]. Therefore, based on the available evidence, to gain diagnostic information, the injection should be performed under ultrasound guidance rather than landmark guidance. Although one of the primary goals of the subacromialsubdeltoid bursa injection in this case is to gain diagnostic information, it would also be advantageous for the injection to provide therapeutic benefit to the patient. Therefore, injection efficacy is of significant importance. Five level 2 studies have compared the efficacy of USG and LMG subacromial-subdeltoid bursa injections [16-20]. All 5 studies demonstrated better outcomes after USG subacromial-subdeltoid bursa injections than after LMG injections. Therefore, to provide the patient with the best outcome, a USG rather than an LMG injection should be performed. Finally, 4 studies to date have compared the costeffectiveness of USG versus LMG injections [21-24]. All 4 studies concluded that USG injections were more costeffective than LMG injections. Although none of the studies specifically evaluated the cost-effectiveness of USG versus LMG subacromial-subdeltoid bursa injections, the current evidence suggests that USG injections are more cost-effective than LMG injections. In conclusion, to provide the patient with diagnostic information, better outcomes, and lower medical costs, I would recommend proceeding with a USG rather than an LMG injection.
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References 1. Hegedus E, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med 2012;46:964-978. 2. Calvert E, Chambers GK, Regan W, Hawkins RH, Leith JM. Special physical examination tests for superior labrum anterior posterior shoulder tears are clinical limited and invalid: A diagnostic systematic review. J Clin Epidemiol 2009;62:558-563. 3. Moosmayer S, Tariz R, Stiris M, Smith HJ. The natural history of asymptomatic rotator cuff tears: A three-year follow-up of fifty cases. J Bone Joint Surg Am 2013;95:1249-1255. 4. Hodgson R, O’Connor PJ, Hensor EM, Barron D, Robinson P. Contrast-enhanced MRI of the subdeltoid, subacromial bursa in
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painful and painful rotator cuff tears. Br J Radiol 2012;85:14821487. Fredericson M, Ho C, Waite B, et al. Magnetic resonance imaging abnormalities in the shoulder and wrist joints of asymptomatic elite athletes. PM R 2009;1:107-116. Eustace JA, Brophy DP, Gibney RP, Bresnihan B, FitzGerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997; 56:59-63. Hanchard N, Shanahan D, Howe T, Thompson J, Goodchild L. Accuracy and dispersal of subacromial and glenohumeral injections in cadavers. J Rheumatol 2006;33:1143-1146. Henkus HE, Cobben LP, Coerkamp EG, Nelissen RG, van Arkel ER. The accuracy of subacromial injections: A prospective randomized magnetic resonance imaging study [see comment]. Arthroscopy 2006;22:277-282. Kang MN, Rizio L, Prybicien M, Middlemas DA, Blacksin MF. The accuracy of subacromial corticosteroid injections: A comparison of multiple methods. J Shoulder Elbow Surg 2008;17(1 suppl): 61S-66S. Mathews PV, Glousman RE. Accuracy of subacromial injection: Anterolateral versus posterior approach. J Shoulder Elbow Surg 2005;14:145-148. Partington PF, Broome GH. Diagnostic injection around the shoulder: Hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg 1998;7:147-150. Rutten MJ, Maresch BJ, Jager GJ, de Waal Malefijt MC. Injection of the subacromial-subdeltoid bursa: Blind or ultrasound-guided? Acta Orthop 2007;78:254-257. Yamakado K. The targeting accuracy of subacromial injection to the shoulder: An arthrographic evaluation. Arthroscopy 2002;18: 887-891. Dogu B, Yucel SD, Sag SY, Bankaoglu M, Kuran B. Blind or ultrasoundguided corticosteroid injections and short-term response in subacromial impingement syndrome: A randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012;91:658-665. Farshad M, Jundt-Ecker M, Sutter R, Schubert M, Gerber C. Does subacromial injection of a local anesthetic influence strength in healthy shoulders? A double-blinded, placebo-controlled study. J Bone Joint Surg Am 2012;94:1751-1755. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographicguided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004;31:308-314. Zufferey P, Revaz S, Degailler X, Balague F, So A. A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain. Joint Bone Spine 2012;79:166-169. Chen MJ, Lew HL, Hsu TC, et al. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006;85:31-35. Hsieh LF, Hsu WC, Lin YJ, Wu SH, Chang KC, Chang HL. Is ultrasound-guided injection more effective in chronic subacromial bursitis? Med Sci Sports Exerc 2013;45:2205-2213. Ucuncu F, Capkin E, Karkucak M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain. Clin J Pain 2009;25: 786-789. Chavez-Chiang N, Delea S, Sibbitt WL, Bankhurst AD, Norton H. Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance. Arthritis Rheum 2010;62(suppl 10): 1626. Sibbitt S, Band PA, Kettwich LG, Chavez-Chiang NR, DeLea SL, Bankhurst AD. A randomized controlled trial evaluating the cost effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol 2011; 17:409-415.
J.T. Finnoff et al. / PM R 7 (2015) 435-442 23. Sibbitt W, Band PA, Chavez-Chiang NR, DeLea SL, Norton HE, Bankhurst AD. A randomized controlled trial of the costeffectiveness of ultrasound-guided intraarticular injection of inflammatory arthritis. J Rheumatol 2011;38:252-263.
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24. Sibbitt W, Kettwich LG, Band PA, et al. Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee? Scand J Rheumatol 2012;41: 66-72.
John G. Costouros, MD, Responds The shoulder is a minimally constrained joint, which allows for a wide range of motion while maintaining stability through a complex interplay of osseous and soft tissue architecture. The control of glenohumeral stability is maintained by static constraints (eg, osteochondral articulation, ligaments, and tendons), as well as dynamic constraints (eg, active muscular contraction) [1]. The osteochondral anatomy of the proximal humerus and glenoid, capsuloligamentous structures, negative intra-articular pressure, synovial fluid adhesion-cohesion, rotator cuff, scapular stabilizers, and biceps tendon all contribute to glenohumeral stability during shoulder motion [2-6]. Pain and dysfunction can result when this complex anatomy is disrupted by inflammation or frank tear due to traumatic injury, microtrauma, aging, or an intrinsic pathologic process. The clinician has several tools that can provide very useful information regarding the condition of a patient with shoulder pain and may be helpful in formulating a differential diagnosis. In this particular case, MJ is 44 years old and has pain that was instigated with overhead sporting activities on his dominant side. The key physical examination findings also offer some insights. Pain with active abduction and internal rotation, in addition to a positive Neer sign and Hawkins-Kennedy test, are considered to be classic signs of subacromial impingement. Although the O’Brien sign is the most common test for superior labral disease (SLAP tears), a variety of other tests have also been reported such as the dynamic labral shear test, biceps load II test, labral tension test, and Speed test. Unfortunately, all of these examination maneuvers have consistently lacked sensitivity and specificity in the literature [7]. Fortunately, in this case we also have the benefit of the shoulder MR arthrogram, which coincides nicely with the suspected condition. Numerous studies have shown that MRI scans are superior to other imaging modalities for the diagnosis of capsulolabral, ligamentous, or rotator cuff lesions [8]. The addition of intra-articular gadolinium further enhances the sensitivity and specificity of MRI in the diagnosis of labral lesions and in distinguishing partial from full-thickness rotator cuff tears [9-11]. Although the clinical and radiographic diagnosis of subacromial impingement is relatively straightforward, the diagnosis of superior labral disease, even with MR arthrography, can be very challenging, and for this reason, selective injections to the shoulder can be especially helpful.
Selective shoulder injections utilizing anesthetic with or without a corticosteroid are useful instruments for diagnostic and therapeutic purposes. Of the commonly used anesthetics, ropivacaine has been shown to be the least toxic to chondrocytes and synoviocytes when compared with other commonly used anesthetics such as lidocaine and bupivacaine [12]. When diagnosing a patient with shoulder pain, it is important to distinguish between a variety of potential pain generators that are evident during clinical examination. Some of the most common areas of the shoulder where diagnostic injection can provide useful information may include the subacromial bursa, long head of the biceps tendon, acromioclavicular joint, sternoclavicular joint, and glenohumeral joint. It should be noted, however, that intra-articular glenohumeral injections, even if accurate, may not be reliable in distinguishing osteochondral from labral or capsular disease given that all of these structures would be anesthetized with an intra-articular injection. Before the more recent widespread use of ultrasound guidance for shoulder injections, clinicians relied on surface anatomy and static imaging modalities to assist in performing accurate injections. Of the various areas of the shoulder where injection can be considered (subacromial bursa, long head of the biceps tendon, acromioclavicular joint, sternoclavicular joint, scapulothoracic joint, and glenohumeral joint), the subacromial bursa is certainly the most straightforward without ultrasound guidance and, in addition, the most commonly performed injection in the shoulder. The surface anatomy and landmarks are easily palpable, and the bursa and subacromial space is easily accessible from posterior, lateral, or anterior approaches. Although some recent studies have reported improved accuracy and clinical efficacy of USG shoulder injections, others have reported the contrary [13-15]. In a randomized, double-blind prospective study of 46 patients with subacromial impingement syndrome who received injections with or without ultrasound guidance, Dogu et al [16] reported no statistically significant difference between groups, both from the standpoint of accuracy of injection (confirmed by MRI) or clinical improvement at 6 weeks after the injection. Interestingly, accuracy of injection was actually higher in patients who did not undergo USG injections (70% versus 65%). In another study, Rutten et al [14] reported on 20 consecutive patients with subacromial impingement
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syndrome who were randomized to receive blind or USG injections. Blind injections were performed by an experienced orthopedic surgeon, the USG injections were performed by a musculoskeletal radiologist, and all injections were confirmed by MRI after the injection. The location of the injection fluid was independently assessed by 2 radiologists who were blinded as to the injection technique used. No significant difference was found between the 2 methods. Studies on glenohumeral joint injections have yielded similar results. In a consecutive series of 166 patients undergoing intra-articular glenohumeral injection via an anterior approach by a musculoskeletal radiologist with the injections confirmed by MRI, the accuracy was reported as 98.2% [17]. Finally, in a consecutive series of 256 patients who underwent an intra-articular injection via an anterior approach with the injections confirmed by arthrography, the accuracy was reported to be 91% [18]. These studies indicate that even with the more challenging intra-articular glenohumeral injections, LMG injections are highly accurate in experienced hands. In a meta-analysis of 5 randomized controlled trials involving 290 patients who underwent LMG versus USG shoulder injections for shoulder pain, Bloom et al [19] concluded that USG injection offered no clinical advantage in terms of pain relief or functional improvement and “that it is not clear that this improves its efficacy to justify the significant added cost.” Furthermore, one must consider the added cost of ultrasound relative to existing methods with respect to fixed costs of equipment, maintenance, training, added clinical time, and diminishing reimbursement from payers. In conclusion, patient MJ has clear evidence of shoulder pain arising from subacromial impingement based on his history, clinical examination, and radiographic findings. It is possible that he may have superimposed superior labral disease, although the accuracy of provocative tests and even MR arthrography are not highly accurate. Despite a very reasonable conservative treatment plan consisting of nonsteroidal antiinflammatory drugs and focused physical therapy, the patient has persistent pain. Proceeding with a diagnostic and potentially therapeutic subacromial injection is a very reasonable next step in treatment. If dramatic temporary or durable clinical improvement is achieved with this injection, this outcome confirms the diagnosis of subacromial impingement as the primary cause of pain and dysfunction in this patient. It would also lead us to believe that the clinical examination and radiographic findings of superior labral disease are not clinically relevant. Based on my experience, as well as the peerreviewed literature previously referenced, there does not appear to be a clear benefit of ultrasound guidance when considering injection into the subacromial space.
A USG injection may be considered in more complex cases, more difficult anatomic areas of the shoulder (eg, the long head biceps tendon sheath and acromioclavicular joint), or in cases in which LMG injection did not produce the expected response. In this current age in which cost containment of health care expenditures is critical and without consistent scientific evidence to prove that USG injections are better than LMG injections to the subacromial space, we as clinicians should be responsible as we consider new technology such as ultrasound in routine, straightforward injections to the shoulder. References 1. Costouros JG, Warner JJP. Glenohumeral instability: Classification, clinical assessment, and imaging. In: Galatz L, ed. Orthopaedic Knowledge Update, Shoulder and Elbow 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008. 2. Harryman DT 2nd, Sidles JA, Harris SL, Matsen FA 3rd. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66. 3. Debski RE, Sakone M, Woo SL, Wong EK, Fu FH, Warner JJ. Contributions of the passive properties of the rotator cuff to glenohumeral stability during anterior-posterior loading. J Shoulder Elbow Surg 1999;8:324-329. 4. Warner JJ, McMahon PJ. The role of the long head of the biceps brachii in superior stability of the glenohumeral joint. J Bone Joint Surg Am 1995;77:366-372. 5. Warner JJ, Deng HX, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:625-685. 6. Lippitt SB, Vanderhooft JE, Harris SL, Sidles JA, Harryman DT 2nd, Matsen FA 3rd. Glenohumeral stability from concavitycompression: A quantitative analysis. J Shoulder Elbow Surg 1993;2:27-34. 7. Cook C, Beaty S, Kissenberth MJ, Siffri P, Pill SG, Hawkins RJ. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg 2012;21:13-22. 8. Jahnke AH Jr, Petersen SA, Neumann C, Steinbach L, Morgan F. A prospective comparison of computerized arthrotomography and magnetic resonance imaging of the glenohumeral joint. Am J Sports Med 1992;20:695-700. discussion 700e701. 9. Dinauer PA, Flemming DJ, Murphy KP, Doukas WC. Diagnosis of superior labral lesions: Comparison of noncontrast MRI with indirect MR arthrography in unexercised shoulders. Skeletal Radiol 2007;36:195-202. 10. Applegate GR, Hewitt M, Snyder SJ, Watson E, Kwak S, Resnick D. Chronic labral tears: value of magnetic resonance arthrography in evaluating the glenoid labrum and labral-bicipital complex. Arthroscopy 2004;20:959-963. 11. Flannigan B, Kursunoglu-Brahme S, Snyder S, Karzel R, Del Pizzo W, Resnick D. MR arthrography of the shoulder: Comparison with conventional MR imaging. AJR Am J Roentgenol 1990;155:829-832. 12. Rao AJ, Johnston TR, Harris AH, Smith RL, Costouros JG. Inhibition of chondrocyte and synovial cell death after exposure to commonly used anesthetics: Chondrocyte apoptosis after anesthetics. Am J Sports Med 2014;42:50-58. 13. Sage W, Pickup L, Smith TO, Denton ER, Toms AP. The clinical and functional outcomes of ultrasound-guided vs landmark-guided injections for adults with shoulder pathologyda systematic review and meta-analysis. Rheumatology (Oxford) 2013;52:743-751. 14. Rutten MJ, Maresch BJ, Jager GJ, de Waal Malefijt MC. Injection of the subacromial-subdeltoid bursa: Blind or ultrasound-guided? Acta Orthop 2007;78:254-257.
J.T. Finnoff et al. / PM R 7 (2015) 435-442 15. Powell SE, Davis SM, Lee EH, et al. Accuracy of palpationdirected intra-articular glenohumeral injection confirmed by magnetic resonance arthrography. Arthroscopy 2015;31: 205-208. 16. Dogu B, Yucel SD, Sag SY, Bankaoglu M, Kuran B. Blind or ultrasound-guided corticosteroid injections and short-term response in subacromial impingement syndrome: A randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012;91: 658-665.
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17. Sidon E, Velkes S, Shemesh S, Levy J, Glaser E, Kosashvili Y. Accuracy of non assisted glenohumeral joint injection in the office setting. Eur J Radiol 2013;82:e829-e831. 18. Jo CH, Shin YH, Shin JS. Accuracy of intra-articular injection of the glenohumeral joint: A modified anterior approach. Arthroscopy 2011;27:1329-1334. 19. Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev 2012;8:CD009147.
Jonathan T. Finnoff, DO, Rebuts I believe that Dr Costouros brings up several appropriate arguments. However, I disagree with his conclusions. As articulated in my initial comments, the pain generator for this patient is in question, and multiple standard nonoperative treatments for shoulder pain have failed to provide relief. Therefore, it is important to clearly identify his pain generator. In my initial comments I also demonstrated that history and physical examination have poor efficacy in identifying a specific pain generator in the shoulder. Multiple studies have demonstrated that radiographically apparent disease does not always correlate with symptoms. An appropriate way to identify this patient’s pain generator is through diagnostic injections. For an injection to provide diagnostic information, it must be accurate (ie, it must reach the intended target). Furthermore, if an injection is going to be performed, it is best to choose the most efficacious and cost-effective injection technique. Dr Costouros cites several studies to support his argument that USG injections are no more accurate or efficacious than LMG injections. I will discuss each of these studies independently to refute his claim. The study by Dogu et al [1] demonstrated symmetrically poor accuracy for both USG and LMG subacromial injections and revealed no appreciable difference in efficacy between the 2 groups. In my opinion, what this study really determined was that USG injections are only accurate if an individual can correctly identify the target of interest and guide the needle into the target using ultrasound. The individuals in this study were obviously unable to do so, and essentially performed unguided injections, which is reflected by the similar accuracy rates between the 2 injection techniques. Furthermore, I would not expect there to be a difference in efficacy between the 2 techniques in this study because the injections had similar accuracy rates. In other words, a difference in accuracy rates is necessary to detect a difference in efficacy. The study by Rutten et al [2] demonstrated 100% accuracy for USG subacromial-subdeltoid bursa injections performed by an experienced musculoskeletal radiologist. Again, if the target can be identified with ultrasound and the needle tip can be placed in the target using ultrasound guidance, this technique should result in 100% accuracy. In this particular study, the
accuracy rate for LMG subacromial-subdeltoid bursa injections performed by an experienced orthopedic surgeon was also 100%. The efficacy was similar between groups. As previously stated, this is to be expected because both groups had the same accuracy rate. Regarding the high accuracy rate of LMG subacromial-subdeltoid bursa injections reported in this study, this appears to be the exception rather than the rule because it is the only study ever to have reported 100% accuracy for LMG subacromial-subdeltoid bursa injections. In fact, authors of the remaining 9 studies who have reported the accuracy of LMG subacromialsubdeltoid bursa injections report their accuracy rates to be 29% [3], 60% [4], 69% [5], 70% [6], 70% [1], 70% [7], 72% [8], 76% [5], 83% [9], and 90% [10], respectively. Not a single one demonstrated 100% accuracy. Thus, based on the available literature, in the hands of an experienced physician, USG subacromial-subdeltoid bursa injections are 100% accurate, whereas the accuracy rates of LMG subacromial-subdeltoid bursa injections are highly variable. Therefore, in order to obtain diagnostic information, ultrasound guidance should be used when performing subacromial-subdeltoid bursa injections. Regarding the accuracy of glenohumeral joint injections, 6 studies with level 1 evidence have evaluated the accuracy of USG injections [11-16]. These studies concluded that USG glenohumeral joint injections were 100% accurate. On the other hand, 7 studies with level 1 evidence have evaluated the accuracy of LMG glenohumeral joint injections [17-23]. The mean accuracy of LMG glenohumeral joint injections reported by these studies was 64%. Similar to the conclusions that can be drawn between LMG and USG subacromial-subdeltoid bursa injections, USG glenohumeral joint injections are more accurate than LMG glenohumeral joint injections. Therefore, when performing an injection for diagnostic purposes into the glenohumeral joint, ultrasound guidance should be used. I have already discussed what I believe to be the reason for the lack of difference in efficacy between USG and LMG studies reported by Dogu et al [1] and Rutten et al [2]. However, the conclusions drawn by Bloom et al [24] in their meta-analysis of imageguided versus blind glucocorticoid injections for shoulder pain are perplexing. They included 5 studies in their
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meta-analysis [25-29]. In reviewing each of these articles, all 5 demonstrated better outcomes in the group that received an USG injection. Although each of the studies had limitations related to their design, and longer-term results demonstrated less difference between groups than did short-term results, to state that USG injections are not more efficacious than LMG injections is contrary to the results of the studies included in their meta-analysis. At this time, only level 2 studies have investigated the efficacy of USG (ie, accurate) subacromial-subdeltoid bursa injections versus LMG (ie, inaccurate) subacromial-subdeltoid bursa injections. Of the 9 studies, 7 demonstrated greater efficacy with USG subacromial-subdeltoid bursa injections [3,25,27,30-33] and 2 demonstrated no difference [1,7]. Therefore, although not every study demonstrated a difference between techniques, the majority (78%) of studies suggest that USG subacromial-subdeltoid bursa injections are more efficacious than LMG subacromialsubdeltoid bursa injections. All of the studies comparing USG glenohumeral joint injections with LMG injections have concluded that USG injections are more efficacious than LMG injections [27,30,34]. Finally, the only mention Dr Costouros makes of costeffectiveness is a quote from the misguided metaanalysis published by Bloom et al [24]. Interestingly, although these investigators weigh in on the costeffectiveness of USG injections, their study did not actually investigate this topic. To date, 4 studies have compared the cost-effectiveness of USG injections versus LMG injections, and all 4 studies concluded that USG injections were more cost-effective than LMG injections. Although none of these studies specifically evaluated the cost-effectiveness of USG versus LMG injections in the subacromial-subdeltoid bursa or glenohumeral joint, the only evidence currently available suggests that USG injections are more cost-effective than LMG injections. In closing, the literature supports the conclusion that USG injections are more accurate, efficacious, and costeffective than LMG injections.
References 1. Dogu B, Yucel SD, Sag SY, Bankaoglu M, Kuran B. Blind or ultrasound-guided corticosteroid injections and short-term response in subacromial impingement syndrome: A randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012;91: 658-665. 2. Rutten MJ, Maresch BJ, Jager GJ, de Waal Malefijt MC. Injection of the subacromial-subdeltoid bursa: Blind or ultrasound-guided? Acta Orthop 2007;78:254-257. 3. Eustace JA, Brophy DP, Gibney RP, Bresnihan B, FitzGerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997; 56:59-63. 4. Mathews PV, Glousman RE. Accuracy of subacromial injection: Anterolateral versus posterior approach. J Shoulder Elbow Surg 2005;14:145-148.
5. Henkus HE, Cobben LP, Coerkamp EG, Nelissen RG, van Arkel ER. The accuracy of subacromial injections: A prospective randomized magnetic resonance imaging study [see comment]. Arthroscopy 2006;22:277-282. 6. Yamakado K. The targeting accuracy of subacromial injection to the shoulder: An arthrographic evaluation. Arthroscopy 2002;18: 887-891. 7. Kang MN, Rizio L, Prybicien M, Middlemas DA, Blacksin MF. The accuracy of subacromial corticosteroid injections: A comparison of multiple methods. J Shoulder Elbow Surg 2008;17(1 suppl): 61S-66S. 8. Hanchard N, Shanahan D, Howe T, Thompson J, Goodchild L. Accuracy and dispersal of subacromial and glenohumeral injections in cadavers. J Rheumatol 2006;33:1143-1146. 9. Partington PF, Broome GH. Diagnostic injection around the shoulder: Hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg 1998;7:147-150. 10. Farshad M, Jundt-Ecker M, Sutter R, Schubert M, Gerber C. Does subacromial injection of a local anesthetic influence strength in healthy shoulders? A double-blinded, placebo-controlled study. J Bone Joint Surg Am 2012;94:1751-1755. 11. Perdikakis E, Drakonaki E, Maris T, Karantanas A. MR arthrography of the shoulder: Tolerance evaluation of four different injection techniques. Skeletal Radiol 2013;42:99-105. 12. Rutten M, Collins JMP, Maresch BJ, Janssen CMM, Kiemeney LALM, Jager GJ. Glenohumeral joint injection: A comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography. Eur Radiol 2009;19:722-730. 13. Choudur H, Ellins ML. Ultrasound-guided gadolinium joint injections for magnetic resonance arthrography. J Clin Ultrasound 2011;39:6-11. 14. Gokalp G, Dusak A, Yazici Z. Efficacy of ultrasonography-guided shoulder MR arthrography using a posterior approach. Skeletal Radiol 2010;39:575-579. 15. Souza P, Aguiar RO, Marchiori E, Bardoe SA. Arthrography of the shoulder: A modified ultrasound guided technique of joint injection at the rotator interval. Eur J Radiol 2010;74:e29-e32. 16. Valls R, Melloni P. Sonographic guidance of needle position for MR arthrography of the shoulder. Am J Roentgenol 1997;169:845-847. 17. Daley E, Bajaj S, Bisson LJ, Cole BJ. Improving injection accuracy of the elbow, knee, and shoulder: Does injection site and imaging make a difference? A systematic review. Am J Sports Med 2011;39: 656-662. 18. Catalano O, Manfredi R, Vanzulli A, Tomei E, Napolitano M, Esposito A. MR arthrography of the glenohumeral joint: Modified posterior approach without imaging guidance. Radiology 2007;242: 550-554. 19. Jo C, Shin YH, Shin JS. Accuracy of intra-articular injection of the glenohumeral joint: A modified anterior approach. Arthroscopy 2011;27:1329-1334. 20. Lopes R, Furtado RN, Parmigiani L, Rosenfeld A, Fernandes AR, Natour J. Accuracy of intra-articular injections in peripheral joints performed blindly in patients with rheumatoid arthritis. Rheumatology (Oxford) 2008;47:1792-1794. 21. Porat S, Leupold JA, Burnett KR, Nottage WM. Reliability of non-imaging-guided glenohumeral joint injection through rotator interval approach in patients undergoing diagnostic MR arthrography. Am J Roentgenol 2008;191:W96-W99. 22. Sethi P, Kingston S, Elattrache N. Accuracy of anterior intraarticular injection of the glenohumeral joint. Arthroscopy 2005; 21:77-80. 23. Tobola A, Cook C, Cassas KJ, Haskins RJ, Wienke JR, Tolan S. Accuracy of glenohumeral joint injections: Comparing approach and experience of provider. J Shoulder Elbow Surg 2011;20: 1147-1154. 24. Bloom J, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev 2012;8:CD009147.
J.T. Finnoff et al. / PM R 7 (2015) 435-442 25. Chen MJ, Lew HL, Hsu TC, et al. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006;85:31-35. 26. Ekeberg OM, Bautz-Holter E, Tveita EK, Juel NG, Kvalheim S, Brox JI. Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: Randomised double blind study [see comment]. BMJ 2009;338:a3112. 27. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographicguided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004;31:308-314. 28. Ucuncu F, Capkin E, Karkucak M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain. Clin J Pain 2009;25:786-789. 29. Lee H, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: Ultrasonography-guided versus blind technique. Phys Med Rehabil 2009;90:1997-2002.
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30. Zufferey P, Revaz S, Degailler X, Balague F, So A. A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain. Joint Bone Spine 2011;79:166-169. 31. Eustace J, Brophy DP, Gibney RP, Bresnihan B, Fitzgerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997; 56:59-63. 32. Hashiuchi T, Sakurai G, Sakamoto Y, Takakura Y, Tanaka Y. Comparative survey of pain-alleviating effects between ultrasoundguided injection and blind injection of lidocaine alone in patients with painful shoulder. Arch Orthop Trauma Surg 2010;130:847-852. 33. Hsieh L, Hsu WC, Lin YJ, Wu SH, Chang KC, Chang HL. Is ultrasound-guided injection more effective in chronic subacromial bursitis? Med Sci Sports Exerc 2013;45:2205-2213. 34. Lee H, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: Ultrasonography-guided versus blind technique. Arch Phys Med Rehabil 2009;90:1997-2002.
John G. Costouros, MD, Responds I read Dr Finnoff’s response with great interest. I agree that the use of ultrasound guidance increases the ability to accurately place a needle at a target tissue. A growing body of literature supports this stance. It is also logical that direct visualization of target tissues allows for accurate needle placement. However, I disagree with several of his subsequent conclusions for a variety of reasons. First, to justify the added costs and physician time associated with utilization of this technology, it must have demonstrated utility beyond mere needle accuracy. In trying to make this claim, Dr Finnoff extols the virtues of the diagnostic utility of this technology. He does this by merely citing the studies that demonstrate the accuracy of needle placement. What he fails to consider is the accuracy and subsequent specificity of the liquid injectate. If a liquid injectate fails to stay where it is placed, then other structures are also anesthetized. Therefore, despite accurate placement of the needle, this noncontained flow results in both decreased diagnostic utility and decreased specificity of the injection. This phenomenon was illustrated in a study by Bergman and Fredericson [1]. In this study, all the subjects underwent a preprocedure MRI for comparison purposes, as well as an anatomic LMG subacromial injection. The injection was followed by immediate postprocedure MRI to determine where the injectate material actually went. The investigators demonstrated that in every procedure a 5-mL injectate tracked to many other places, including the trapezius, deltoid, and rotator cuff muscles, and that the locations varied. Therefore it is clear that soft tissue injections, such as the subacromial bursae injection in this scenario, have low specificity because of the potential spread of the local anesthetic. This result is likely different from that of joint injections, in which the joint capsule could potentially contain the injectate. This capsular containment may increase the specificity of intra-articular injections. In my opinion it may actually be intra-articular injections or injections performed
around sensitive neural structures where the real utility lies for image guidance, including ultrasound guidance. Even if concerns about the specificity of the injectate were nullified, additional concerns with the diagnostic utility of injections arise. Specifically, physicians must recognize that false-positive rates of close to 40% have been documented in the literature for single diagnostic injections [2], which further hinders the ability to interpret a positive response to these injections. Therefore, the real utility of a single diagnostic injection is likely in persons with a negative response because of the low likelihood of a target tissue not responding to a local anesthetic. With this in mind, a negative response helps effectively rule out a target tissue as a potential pain generator. Stated another way, if a tissue is injected and the patient’s pain is not relieved, then that structure is not the source of pain, thereby allowing the physician to focus on other potential pain generators. Accordingly, any injection that actually reaches the target tissue would be effective for this purpose. This raises the question of how often the injectate from an anatomic LMG subacromial bursa injection actually reaches the subacromial bursa. The aforementioned study by Bergman and Fredericson [1] found that an anatomic LMG injection of anesthetic into the subacromial bursa reached the bursa in 100% of the subacromial injections. Thus the ability to determine if a patient is a nonresponder to the diagnostic injection (and effectively rule out the subacromial bursa as the pain generator) would be present even without image guidance. In this specific case, a positive response (with or without imaging) would be difficult to interpret because of placebo rates and noncontained flow of the injectate. However, a practitioner could feel confident about a negative response (with or without image guidance), allowing his or her attention to be focused elsewhere. Therefore, the addition of ultrasound offers limited diagnostic utility for this type of injection.
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Dr Finnoff also cites several studies as evidence of the enhanced efficacy afforded by the addition of ultrasound guidance. Upon review of the 5 cited studies, serious flaws are evident in each that limit their usefulness. Three of the studies actually failed to demonstrate a clinically detectable difference of 2 points on a 10-point pain scale between groups [3-5]. One study failed to report any pain outcomes [6], and in another study a heterogeneous group of patients were injected, including those with calcific tendonitis [7]. Additionally, all studies had the flaw of lack of appropriate blinding, which is a concern given the possibility of increased placebo rates with the use of additional technology. What is still lacking in the literature is a simple study showing a clinically detectable difference in efficacy for a subacromial bursa injection on a homogenous patient population when compared with an anatomic LMG injection with sham ultrasound guidance. Additionally, Dr Finnoff cites numerous studies regarding the cost-effectiveness of ultrasound guidance. None of these studies included patients receiving subacromial bursa injections. In fact, all included either intraarticular joint injections or even carpal tunnel syndrome, which, as previously mentioned, may be an area where ultrasound guidance does offer an advantage. Lastly, an additional concern is the recent rapid increase in ultrasound utilization performed by a large number of physicians who have learned this advanced technique from weekend courses. This situation,
combined with no formal competency recognition from the American College of Graduate Medical Education, raises questions and concerns regarding the true reliability and accuracy of this technique as performed by physicians at large. Given all of these concerns, it is clear that for the scenario presented, the addition of ultrasound guidance should not be considered routine or standard practice because it does not add diagnostic utility, enhance outcomes, or result in cost-effective care. References 1. Bergman AG, Fredericson M. Shoulder MRI after impingement test injection. Skeletal Radiol 1998;27:365-368. 2. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994;58:195-200. 3. Zufferey P, Revaz S, Degailler X, Balague F, So A. A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain. Joint Bone Spine 2012;79:166-169. 4. Ucuncu F, Capkin E, Karcukak M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain. Clin J Pain 2009;25:786-789. 5. Hsieh L-F, Hsu WC, Lin YJ, Wu SH, Chang KC, Chang HL. Is ultrasound-guided injection more effective in chronic subacromial bursitis? Med Sci Sports Exerc 2013;45:2205-2213. 6. Chen MJL, Lew HL, Hsu TC, et al. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006;85:31-35. 7. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographicguided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004;31:308-314.
Disclosure J.T.F. Mayo Clinic Sports Medicine Center, Minneapolis, MN Disclosure: nothing to disclose J.G.C. Department of Orthopaedics, Stanford University, Redwood City, CA Disclosure: nothing to disclose
D.J.K. Department of Orthopaedics, Stanford University, MC 6342, 450 Broadway St, Redwood City, CA 94063. Address correspondence to: D.J.K.; e-mail: [email protected] Disclosure: nothing to disclose
Web Poll Question For the case scenario presented in this Point/Counterpoint, which approach would you take? a. Use ultrasound guidance for shoulder injection b. Perform shoulder injection without ultrasound guidance To cast your vote, visit www.pmrjournal.org
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Point/Counterpoint
Guest Discussants: Jonathan T. Finnoff, DO, John G. Costouros, MD Feature Editor: David J. Kennedy, MD
Is Ultrasound Guidance Needed for Shoulder Injections? CASE SCENARIO MJ is a 44-year-old teacher who has had right lateral shoulder pain for 5 weeks. The pain developed acutely after he played a pickup game of basketball. He initially presented to his primary care physician, who suspected an acute rotator cuff injury and prescribed naproxen, 500 mg twice daily, along with physical therapy. MJ has completed 4 weeks of appropriate therapy focusing on scapular retraction exercise, pectoralis stretching, and rotator cuff strengthening. He experienced no relief from the therapy or medication, so his primary care physician obtained a shoulder magnetic resonance (MR) arthrogram, which demonstrated thickening of the subacromial-subdeltoid bursa, suggestive of bursitis, and a type I superior labral anterior to posterior (SLAP) lesion. MJ was sent to you for further evaluation and treatment. He currently has a 7 out of 10 level of pain over the anterolateral shoulder that is worse when he performs overhead maneuvers and sleeps on his right side. Upon physical examination he has no tenderness to palpation but experiences pain during active range of motion testing, particularly with internal rotation and abduction, respectively. He also has a positive Hawkins-Kennedy test, Neer sign, and O’Brien test. He has difficulty deciding whether his characteristic pain is reproduced more by the impingement maneuvers or labral maneuver. Neurovascularly, he is intact. You discuss treatment options, and given the failure of conservative treatments thus far, he wishes to pursue a corticosteroid injection in the subacromial bursa. He recently saw a commercial on TV featuring an injection that was performed with ultrasound guidance and asks if ultrasound guidance should be used to perform his injection. Dr Jonathan Finnoff will argue that ultrasound guidance should be used for the injection, and Dr John Costouros will argue that ultrasound guidance is not needed. Jonathan T. Finnoff, DO This scenario is not uncommon. Several important factors must be considered when determining what to do next. First, because several commonly used treatments have failed, one needs to consider whether the working diagnosis is correct. In this case, the patient’s physical examination and MR arthrogram suggest 2 possible causes for the pain, namely subacromial-subdeltoid bursopathy or labral disease. However, it is not known whether one or both of these conditions are responsible for this patient’s pain. It is well known that many shoulder physical examination maneuvers have limited sensitivity and specificity. A recent meta-analysis found the pooled sensitivity and specificity for the Neer sign to be 72% and 60%, respectively, and the sensitivity and specificity of the Hawkins-Kennedy test was 79% and 59%, respectively [1]. Another systematic review concluded that
physical examination tests for SLAP tears were invalid and of limited clinical value [2]. Furthermore, multiple studies have established that patients can have pathologic findings on magnetic resonance imaging (MRI) with no associated symptoms [3-5]. Therefore, based on the available information, it can be concluded that the mechanism generating the patient’s pain is not known with any type of surety. Because the treatment for labral disease is very different from that for subacromial-subdeltoid bursopathy, the first thing that needs to be done is to determine what is causing the patient’s pain. One way to determine what is causing the patient’s pain is to perform diagnostic injections. A diagnostic injection involves guiding a needle to a specific structure and injecting a local anesthetic into the structure (in the case of a joint or bursa) or around the structure
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.03.011
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(in the case of a nerve). If the patient’s symptoms are relieved for the duration of the local anesthetic, it can be concluded that the structure that was anesthetized during the procedure is generating the pain. However, the ability to gain diagnostic information from an injection is predicated upon placing the medication in a specific location. In other words, the injection needs to be accurate or it doesn’t provide any diagnostic information. Ten studies with level 1 or 2 evidence have been performed to evaluate the accuracy of landmark-guided (LMG) subacromial-subdeltoid bursa injections and have concluded that the mean accuracy is 80% [6-15]. Authors of a study with level 1 evidence reported that the accuracy of ultrasound-guided (USG) subacromialsubdeltoid bursa injections was 100% [12]. Therefore, based on the available evidence, to gain diagnostic information, the injection should be performed under ultrasound guidance rather than landmark guidance. Although one of the primary goals of the subacromialsubdeltoid bursa injection in this case is to gain diagnostic information, it would also be advantageous for the injection to provide therapeutic benefit to the patient. Therefore, injection efficacy is of significant importance. Five level 2 studies have compared the efficacy of USG and LMG subacromial-subdeltoid bursa injections [16-20]. All 5 studies demonstrated better outcomes after USG subacromial-subdeltoid bursa injections than after LMG injections. Therefore, to provide the patient with the best outcome, a USG rather than an LMG injection should be performed. Finally, 4 studies to date have compared the costeffectiveness of USG versus LMG injections [21-24]. All 4 studies concluded that USG injections were more costeffective than LMG injections. Although none of the studies specifically evaluated the cost-effectiveness of USG versus LMG subacromial-subdeltoid bursa injections, the current evidence suggests that USG injections are more cost-effective than LMG injections. In conclusion, to provide the patient with diagnostic information, better outcomes, and lower medical costs, I would recommend proceeding with a USG rather than an LMG injection.
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References 1. Hegedus E, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med 2012;46:964-978. 2. Calvert E, Chambers GK, Regan W, Hawkins RH, Leith JM. Special physical examination tests for superior labrum anterior posterior shoulder tears are clinical limited and invalid: A diagnostic systematic review. J Clin Epidemiol 2009;62:558-563. 3. Moosmayer S, Tariz R, Stiris M, Smith HJ. The natural history of asymptomatic rotator cuff tears: A three-year follow-up of fifty cases. J Bone Joint Surg Am 2013;95:1249-1255. 4. Hodgson R, O’Connor PJ, Hensor EM, Barron D, Robinson P. Contrast-enhanced MRI of the subdeltoid, subacromial bursa in
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painful and painful rotator cuff tears. Br J Radiol 2012;85:14821487. Fredericson M, Ho C, Waite B, et al. Magnetic resonance imaging abnormalities in the shoulder and wrist joints of asymptomatic elite athletes. PM R 2009;1:107-116. Eustace JA, Brophy DP, Gibney RP, Bresnihan B, FitzGerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997; 56:59-63. Hanchard N, Shanahan D, Howe T, Thompson J, Goodchild L. Accuracy and dispersal of subacromial and glenohumeral injections in cadavers. J Rheumatol 2006;33:1143-1146. Henkus HE, Cobben LP, Coerkamp EG, Nelissen RG, van Arkel ER. The accuracy of subacromial injections: A prospective randomized magnetic resonance imaging study [see comment]. Arthroscopy 2006;22:277-282. Kang MN, Rizio L, Prybicien M, Middlemas DA, Blacksin MF. The accuracy of subacromial corticosteroid injections: A comparison of multiple methods. J Shoulder Elbow Surg 2008;17(1 suppl): 61S-66S. Mathews PV, Glousman RE. Accuracy of subacromial injection: Anterolateral versus posterior approach. J Shoulder Elbow Surg 2005;14:145-148. Partington PF, Broome GH. Diagnostic injection around the shoulder: Hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg 1998;7:147-150. Rutten MJ, Maresch BJ, Jager GJ, de Waal Malefijt MC. Injection of the subacromial-subdeltoid bursa: Blind or ultrasound-guided? Acta Orthop 2007;78:254-257. Yamakado K. The targeting accuracy of subacromial injection to the shoulder: An arthrographic evaluation. Arthroscopy 2002;18: 887-891. Dogu B, Yucel SD, Sag SY, Bankaoglu M, Kuran B. Blind or ultrasoundguided corticosteroid injections and short-term response in subacromial impingement syndrome: A randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012;91:658-665. Farshad M, Jundt-Ecker M, Sutter R, Schubert M, Gerber C. Does subacromial injection of a local anesthetic influence strength in healthy shoulders? A double-blinded, placebo-controlled study. J Bone Joint Surg Am 2012;94:1751-1755. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographicguided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004;31:308-314. Zufferey P, Revaz S, Degailler X, Balague F, So A. A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain. Joint Bone Spine 2012;79:166-169. Chen MJ, Lew HL, Hsu TC, et al. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006;85:31-35. Hsieh LF, Hsu WC, Lin YJ, Wu SH, Chang KC, Chang HL. Is ultrasound-guided injection more effective in chronic subacromial bursitis? Med Sci Sports Exerc 2013;45:2205-2213. Ucuncu F, Capkin E, Karkucak M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain. Clin J Pain 2009;25: 786-789. Chavez-Chiang N, Delea S, Sibbitt WL, Bankhurst AD, Norton H. Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance. Arthritis Rheum 2010;62(suppl 10): 1626. Sibbitt S, Band PA, Kettwich LG, Chavez-Chiang NR, DeLea SL, Bankhurst AD. A randomized controlled trial evaluating the cost effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol 2011; 17:409-415.
J.T. Finnoff et al. / PM R 7 (2015) 435-442 23. Sibbitt W, Band PA, Chavez-Chiang NR, DeLea SL, Norton HE, Bankhurst AD. A randomized controlled trial of the costeffectiveness of ultrasound-guided intraarticular injection of inflammatory arthritis. J Rheumatol 2011;38:252-263.
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24. Sibbitt W, Kettwich LG, Band PA, et al. Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee? Scand J Rheumatol 2012;41: 66-72.
John G. Costouros, MD, Responds The shoulder is a minimally constrained joint, which allows for a wide range of motion while maintaining stability through a complex interplay of osseous and soft tissue architecture. The control of glenohumeral stability is maintained by static constraints (eg, osteochondral articulation, ligaments, and tendons), as well as dynamic constraints (eg, active muscular contraction) [1]. The osteochondral anatomy of the proximal humerus and glenoid, capsuloligamentous structures, negative intra-articular pressure, synovial fluid adhesion-cohesion, rotator cuff, scapular stabilizers, and biceps tendon all contribute to glenohumeral stability during shoulder motion [2-6]. Pain and dysfunction can result when this complex anatomy is disrupted by inflammation or frank tear due to traumatic injury, microtrauma, aging, or an intrinsic pathologic process. The clinician has several tools that can provide very useful information regarding the condition of a patient with shoulder pain and may be helpful in formulating a differential diagnosis. In this particular case, MJ is 44 years old and has pain that was instigated with overhead sporting activities on his dominant side. The key physical examination findings also offer some insights. Pain with active abduction and internal rotation, in addition to a positive Neer sign and Hawkins-Kennedy test, are considered to be classic signs of subacromial impingement. Although the O’Brien sign is the most common test for superior labral disease (SLAP tears), a variety of other tests have also been reported such as the dynamic labral shear test, biceps load II test, labral tension test, and Speed test. Unfortunately, all of these examination maneuvers have consistently lacked sensitivity and specificity in the literature [7]. Fortunately, in this case we also have the benefit of the shoulder MR arthrogram, which coincides nicely with the suspected condition. Numerous studies have shown that MRI scans are superior to other imaging modalities for the diagnosis of capsulolabral, ligamentous, or rotator cuff lesions [8]. The addition of intra-articular gadolinium further enhances the sensitivity and specificity of MRI in the diagnosis of labral lesions and in distinguishing partial from full-thickness rotator cuff tears [9-11]. Although the clinical and radiographic diagnosis of subacromial impingement is relatively straightforward, the diagnosis of superior labral disease, even with MR arthrography, can be very challenging, and for this reason, selective injections to the shoulder can be especially helpful.
Selective shoulder injections utilizing anesthetic with or without a corticosteroid are useful instruments for diagnostic and therapeutic purposes. Of the commonly used anesthetics, ropivacaine has been shown to be the least toxic to chondrocytes and synoviocytes when compared with other commonly used anesthetics such as lidocaine and bupivacaine [12]. When diagnosing a patient with shoulder pain, it is important to distinguish between a variety of potential pain generators that are evident during clinical examination. Some of the most common areas of the shoulder where diagnostic injection can provide useful information may include the subacromial bursa, long head of the biceps tendon, acromioclavicular joint, sternoclavicular joint, and glenohumeral joint. It should be noted, however, that intra-articular glenohumeral injections, even if accurate, may not be reliable in distinguishing osteochondral from labral or capsular disease given that all of these structures would be anesthetized with an intra-articular injection. Before the more recent widespread use of ultrasound guidance for shoulder injections, clinicians relied on surface anatomy and static imaging modalities to assist in performing accurate injections. Of the various areas of the shoulder where injection can be considered (subacromial bursa, long head of the biceps tendon, acromioclavicular joint, sternoclavicular joint, scapulothoracic joint, and glenohumeral joint), the subacromial bursa is certainly the most straightforward without ultrasound guidance and, in addition, the most commonly performed injection in the shoulder. The surface anatomy and landmarks are easily palpable, and the bursa and subacromial space is easily accessible from posterior, lateral, or anterior approaches. Although some recent studies have reported improved accuracy and clinical efficacy of USG shoulder injections, others have reported the contrary [13-15]. In a randomized, double-blind prospective study of 46 patients with subacromial impingement syndrome who received injections with or without ultrasound guidance, Dogu et al [16] reported no statistically significant difference between groups, both from the standpoint of accuracy of injection (confirmed by MRI) or clinical improvement at 6 weeks after the injection. Interestingly, accuracy of injection was actually higher in patients who did not undergo USG injections (70% versus 65%). In another study, Rutten et al [14] reported on 20 consecutive patients with subacromial impingement
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syndrome who were randomized to receive blind or USG injections. Blind injections were performed by an experienced orthopedic surgeon, the USG injections were performed by a musculoskeletal radiologist, and all injections were confirmed by MRI after the injection. The location of the injection fluid was independently assessed by 2 radiologists who were blinded as to the injection technique used. No significant difference was found between the 2 methods. Studies on glenohumeral joint injections have yielded similar results. In a consecutive series of 166 patients undergoing intra-articular glenohumeral injection via an anterior approach by a musculoskeletal radiologist with the injections confirmed by MRI, the accuracy was reported as 98.2% [17]. Finally, in a consecutive series of 256 patients who underwent an intra-articular injection via an anterior approach with the injections confirmed by arthrography, the accuracy was reported to be 91% [18]. These studies indicate that even with the more challenging intra-articular glenohumeral injections, LMG injections are highly accurate in experienced hands. In a meta-analysis of 5 randomized controlled trials involving 290 patients who underwent LMG versus USG shoulder injections for shoulder pain, Bloom et al [19] concluded that USG injection offered no clinical advantage in terms of pain relief or functional improvement and “that it is not clear that this improves its efficacy to justify the significant added cost.” Furthermore, one must consider the added cost of ultrasound relative to existing methods with respect to fixed costs of equipment, maintenance, training, added clinical time, and diminishing reimbursement from payers. In conclusion, patient MJ has clear evidence of shoulder pain arising from subacromial impingement based on his history, clinical examination, and radiographic findings. It is possible that he may have superimposed superior labral disease, although the accuracy of provocative tests and even MR arthrography are not highly accurate. Despite a very reasonable conservative treatment plan consisting of nonsteroidal antiinflammatory drugs and focused physical therapy, the patient has persistent pain. Proceeding with a diagnostic and potentially therapeutic subacromial injection is a very reasonable next step in treatment. If dramatic temporary or durable clinical improvement is achieved with this injection, this outcome confirms the diagnosis of subacromial impingement as the primary cause of pain and dysfunction in this patient. It would also lead us to believe that the clinical examination and radiographic findings of superior labral disease are not clinically relevant. Based on my experience, as well as the peerreviewed literature previously referenced, there does not appear to be a clear benefit of ultrasound guidance when considering injection into the subacromial space.
A USG injection may be considered in more complex cases, more difficult anatomic areas of the shoulder (eg, the long head biceps tendon sheath and acromioclavicular joint), or in cases in which LMG injection did not produce the expected response. In this current age in which cost containment of health care expenditures is critical and without consistent scientific evidence to prove that USG injections are better than LMG injections to the subacromial space, we as clinicians should be responsible as we consider new technology such as ultrasound in routine, straightforward injections to the shoulder. References 1. Costouros JG, Warner JJP. Glenohumeral instability: Classification, clinical assessment, and imaging. In: Galatz L, ed. Orthopaedic Knowledge Update, Shoulder and Elbow 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008. 2. Harryman DT 2nd, Sidles JA, Harris SL, Matsen FA 3rd. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66. 3. Debski RE, Sakone M, Woo SL, Wong EK, Fu FH, Warner JJ. Contributions of the passive properties of the rotator cuff to glenohumeral stability during anterior-posterior loading. J Shoulder Elbow Surg 1999;8:324-329. 4. Warner JJ, McMahon PJ. The role of the long head of the biceps brachii in superior stability of the glenohumeral joint. J Bone Joint Surg Am 1995;77:366-372. 5. Warner JJ, Deng HX, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:625-685. 6. Lippitt SB, Vanderhooft JE, Harris SL, Sidles JA, Harryman DT 2nd, Matsen FA 3rd. Glenohumeral stability from concavitycompression: A quantitative analysis. J Shoulder Elbow Surg 1993;2:27-34. 7. Cook C, Beaty S, Kissenberth MJ, Siffri P, Pill SG, Hawkins RJ. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg 2012;21:13-22. 8. Jahnke AH Jr, Petersen SA, Neumann C, Steinbach L, Morgan F. A prospective comparison of computerized arthrotomography and magnetic resonance imaging of the glenohumeral joint. Am J Sports Med 1992;20:695-700. discussion 700e701. 9. Dinauer PA, Flemming DJ, Murphy KP, Doukas WC. Diagnosis of superior labral lesions: Comparison of noncontrast MRI with indirect MR arthrography in unexercised shoulders. Skeletal Radiol 2007;36:195-202. 10. Applegate GR, Hewitt M, Snyder SJ, Watson E, Kwak S, Resnick D. Chronic labral tears: value of magnetic resonance arthrography in evaluating the glenoid labrum and labral-bicipital complex. Arthroscopy 2004;20:959-963. 11. Flannigan B, Kursunoglu-Brahme S, Snyder S, Karzel R, Del Pizzo W, Resnick D. MR arthrography of the shoulder: Comparison with conventional MR imaging. AJR Am J Roentgenol 1990;155:829-832. 12. Rao AJ, Johnston TR, Harris AH, Smith RL, Costouros JG. Inhibition of chondrocyte and synovial cell death after exposure to commonly used anesthetics: Chondrocyte apoptosis after anesthetics. Am J Sports Med 2014;42:50-58. 13. Sage W, Pickup L, Smith TO, Denton ER, Toms AP. The clinical and functional outcomes of ultrasound-guided vs landmark-guided injections for adults with shoulder pathologyda systematic review and meta-analysis. Rheumatology (Oxford) 2013;52:743-751. 14. Rutten MJ, Maresch BJ, Jager GJ, de Waal Malefijt MC. Injection of the subacromial-subdeltoid bursa: Blind or ultrasound-guided? Acta Orthop 2007;78:254-257.
J.T. Finnoff et al. / PM R 7 (2015) 435-442 15. Powell SE, Davis SM, Lee EH, et al. Accuracy of palpationdirected intra-articular glenohumeral injection confirmed by magnetic resonance arthrography. Arthroscopy 2015;31: 205-208. 16. Dogu B, Yucel SD, Sag SY, Bankaoglu M, Kuran B. Blind or ultrasound-guided corticosteroid injections and short-term response in subacromial impingement syndrome: A randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012;91: 658-665.
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17. Sidon E, Velkes S, Shemesh S, Levy J, Glaser E, Kosashvili Y. Accuracy of non assisted glenohumeral joint injection in the office setting. Eur J Radiol 2013;82:e829-e831. 18. Jo CH, Shin YH, Shin JS. Accuracy of intra-articular injection of the glenohumeral joint: A modified anterior approach. Arthroscopy 2011;27:1329-1334. 19. Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev 2012;8:CD009147.
Jonathan T. Finnoff, DO, Rebuts I believe that Dr Costouros brings up several appropriate arguments. However, I disagree with his conclusions. As articulated in my initial comments, the pain generator for this patient is in question, and multiple standard nonoperative treatments for shoulder pain have failed to provide relief. Therefore, it is important to clearly identify his pain generator. In my initial comments I also demonstrated that history and physical examination have poor efficacy in identifying a specific pain generator in the shoulder. Multiple studies have demonstrated that radiographically apparent disease does not always correlate with symptoms. An appropriate way to identify this patient’s pain generator is through diagnostic injections. For an injection to provide diagnostic information, it must be accurate (ie, it must reach the intended target). Furthermore, if an injection is going to be performed, it is best to choose the most efficacious and cost-effective injection technique. Dr Costouros cites several studies to support his argument that USG injections are no more accurate or efficacious than LMG injections. I will discuss each of these studies independently to refute his claim. The study by Dogu et al [1] demonstrated symmetrically poor accuracy for both USG and LMG subacromial injections and revealed no appreciable difference in efficacy between the 2 groups. In my opinion, what this study really determined was that USG injections are only accurate if an individual can correctly identify the target of interest and guide the needle into the target using ultrasound. The individuals in this study were obviously unable to do so, and essentially performed unguided injections, which is reflected by the similar accuracy rates between the 2 injection techniques. Furthermore, I would not expect there to be a difference in efficacy between the 2 techniques in this study because the injections had similar accuracy rates. In other words, a difference in accuracy rates is necessary to detect a difference in efficacy. The study by Rutten et al [2] demonstrated 100% accuracy for USG subacromial-subdeltoid bursa injections performed by an experienced musculoskeletal radiologist. Again, if the target can be identified with ultrasound and the needle tip can be placed in the target using ultrasound guidance, this technique should result in 100% accuracy. In this particular study, the
accuracy rate for LMG subacromial-subdeltoid bursa injections performed by an experienced orthopedic surgeon was also 100%. The efficacy was similar between groups. As previously stated, this is to be expected because both groups had the same accuracy rate. Regarding the high accuracy rate of LMG subacromial-subdeltoid bursa injections reported in this study, this appears to be the exception rather than the rule because it is the only study ever to have reported 100% accuracy for LMG subacromial-subdeltoid bursa injections. In fact, authors of the remaining 9 studies who have reported the accuracy of LMG subacromialsubdeltoid bursa injections report their accuracy rates to be 29% [3], 60% [4], 69% [5], 70% [6], 70% [1], 70% [7], 72% [8], 76% [5], 83% [9], and 90% [10], respectively. Not a single one demonstrated 100% accuracy. Thus, based on the available literature, in the hands of an experienced physician, USG subacromial-subdeltoid bursa injections are 100% accurate, whereas the accuracy rates of LMG subacromial-subdeltoid bursa injections are highly variable. Therefore, in order to obtain diagnostic information, ultrasound guidance should be used when performing subacromial-subdeltoid bursa injections. Regarding the accuracy of glenohumeral joint injections, 6 studies with level 1 evidence have evaluated the accuracy of USG injections [11-16]. These studies concluded that USG glenohumeral joint injections were 100% accurate. On the other hand, 7 studies with level 1 evidence have evaluated the accuracy of LMG glenohumeral joint injections [17-23]. The mean accuracy of LMG glenohumeral joint injections reported by these studies was 64%. Similar to the conclusions that can be drawn between LMG and USG subacromial-subdeltoid bursa injections, USG glenohumeral joint injections are more accurate than LMG glenohumeral joint injections. Therefore, when performing an injection for diagnostic purposes into the glenohumeral joint, ultrasound guidance should be used. I have already discussed what I believe to be the reason for the lack of difference in efficacy between USG and LMG studies reported by Dogu et al [1] and Rutten et al [2]. However, the conclusions drawn by Bloom et al [24] in their meta-analysis of imageguided versus blind glucocorticoid injections for shoulder pain are perplexing. They included 5 studies in their
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meta-analysis [25-29]. In reviewing each of these articles, all 5 demonstrated better outcomes in the group that received an USG injection. Although each of the studies had limitations related to their design, and longer-term results demonstrated less difference between groups than did short-term results, to state that USG injections are not more efficacious than LMG injections is contrary to the results of the studies included in their meta-analysis. At this time, only level 2 studies have investigated the efficacy of USG (ie, accurate) subacromial-subdeltoid bursa injections versus LMG (ie, inaccurate) subacromial-subdeltoid bursa injections. Of the 9 studies, 7 demonstrated greater efficacy with USG subacromial-subdeltoid bursa injections [3,25,27,30-33] and 2 demonstrated no difference [1,7]. Therefore, although not every study demonstrated a difference between techniques, the majority (78%) of studies suggest that USG subacromial-subdeltoid bursa injections are more efficacious than LMG subacromialsubdeltoid bursa injections. All of the studies comparing USG glenohumeral joint injections with LMG injections have concluded that USG injections are more efficacious than LMG injections [27,30,34]. Finally, the only mention Dr Costouros makes of costeffectiveness is a quote from the misguided metaanalysis published by Bloom et al [24]. Interestingly, although these investigators weigh in on the costeffectiveness of USG injections, their study did not actually investigate this topic. To date, 4 studies have compared the cost-effectiveness of USG injections versus LMG injections, and all 4 studies concluded that USG injections were more cost-effective than LMG injections. Although none of these studies specifically evaluated the cost-effectiveness of USG versus LMG injections in the subacromial-subdeltoid bursa or glenohumeral joint, the only evidence currently available suggests that USG injections are more cost-effective than LMG injections. In closing, the literature supports the conclusion that USG injections are more accurate, efficacious, and costeffective than LMG injections.
References 1. Dogu B, Yucel SD, Sag SY, Bankaoglu M, Kuran B. Blind or ultrasound-guided corticosteroid injections and short-term response in subacromial impingement syndrome: A randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012;91: 658-665. 2. Rutten MJ, Maresch BJ, Jager GJ, de Waal Malefijt MC. Injection of the subacromial-subdeltoid bursa: Blind or ultrasound-guided? Acta Orthop 2007;78:254-257. 3. Eustace JA, Brophy DP, Gibney RP, Bresnihan B, FitzGerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997; 56:59-63. 4. Mathews PV, Glousman RE. Accuracy of subacromial injection: Anterolateral versus posterior approach. J Shoulder Elbow Surg 2005;14:145-148.
5. Henkus HE, Cobben LP, Coerkamp EG, Nelissen RG, van Arkel ER. The accuracy of subacromial injections: A prospective randomized magnetic resonance imaging study [see comment]. Arthroscopy 2006;22:277-282. 6. Yamakado K. The targeting accuracy of subacromial injection to the shoulder: An arthrographic evaluation. Arthroscopy 2002;18: 887-891. 7. Kang MN, Rizio L, Prybicien M, Middlemas DA, Blacksin MF. The accuracy of subacromial corticosteroid injections: A comparison of multiple methods. J Shoulder Elbow Surg 2008;17(1 suppl): 61S-66S. 8. Hanchard N, Shanahan D, Howe T, Thompson J, Goodchild L. Accuracy and dispersal of subacromial and glenohumeral injections in cadavers. J Rheumatol 2006;33:1143-1146. 9. Partington PF, Broome GH. Diagnostic injection around the shoulder: Hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg 1998;7:147-150. 10. Farshad M, Jundt-Ecker M, Sutter R, Schubert M, Gerber C. Does subacromial injection of a local anesthetic influence strength in healthy shoulders? A double-blinded, placebo-controlled study. J Bone Joint Surg Am 2012;94:1751-1755. 11. Perdikakis E, Drakonaki E, Maris T, Karantanas A. MR arthrography of the shoulder: Tolerance evaluation of four different injection techniques. Skeletal Radiol 2013;42:99-105. 12. Rutten M, Collins JMP, Maresch BJ, Janssen CMM, Kiemeney LALM, Jager GJ. Glenohumeral joint injection: A comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography. Eur Radiol 2009;19:722-730. 13. Choudur H, Ellins ML. Ultrasound-guided gadolinium joint injections for magnetic resonance arthrography. J Clin Ultrasound 2011;39:6-11. 14. Gokalp G, Dusak A, Yazici Z. Efficacy of ultrasonography-guided shoulder MR arthrography using a posterior approach. Skeletal Radiol 2010;39:575-579. 15. Souza P, Aguiar RO, Marchiori E, Bardoe SA. Arthrography of the shoulder: A modified ultrasound guided technique of joint injection at the rotator interval. Eur J Radiol 2010;74:e29-e32. 16. Valls R, Melloni P. Sonographic guidance of needle position for MR arthrography of the shoulder. Am J Roentgenol 1997;169:845-847. 17. Daley E, Bajaj S, Bisson LJ, Cole BJ. Improving injection accuracy of the elbow, knee, and shoulder: Does injection site and imaging make a difference? A systematic review. Am J Sports Med 2011;39: 656-662. 18. Catalano O, Manfredi R, Vanzulli A, Tomei E, Napolitano M, Esposito A. MR arthrography of the glenohumeral joint: Modified posterior approach without imaging guidance. Radiology 2007;242: 550-554. 19. Jo C, Shin YH, Shin JS. Accuracy of intra-articular injection of the glenohumeral joint: A modified anterior approach. Arthroscopy 2011;27:1329-1334. 20. Lopes R, Furtado RN, Parmigiani L, Rosenfeld A, Fernandes AR, Natour J. Accuracy of intra-articular injections in peripheral joints performed blindly in patients with rheumatoid arthritis. Rheumatology (Oxford) 2008;47:1792-1794. 21. Porat S, Leupold JA, Burnett KR, Nottage WM. Reliability of non-imaging-guided glenohumeral joint injection through rotator interval approach in patients undergoing diagnostic MR arthrography. Am J Roentgenol 2008;191:W96-W99. 22. Sethi P, Kingston S, Elattrache N. Accuracy of anterior intraarticular injection of the glenohumeral joint. Arthroscopy 2005; 21:77-80. 23. Tobola A, Cook C, Cassas KJ, Haskins RJ, Wienke JR, Tolan S. Accuracy of glenohumeral joint injections: Comparing approach and experience of provider. J Shoulder Elbow Surg 2011;20: 1147-1154. 24. Bloom J, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev 2012;8:CD009147.
J.T. Finnoff et al. / PM R 7 (2015) 435-442 25. Chen MJ, Lew HL, Hsu TC, et al. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006;85:31-35. 26. Ekeberg OM, Bautz-Holter E, Tveita EK, Juel NG, Kvalheim S, Brox JI. Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: Randomised double blind study [see comment]. BMJ 2009;338:a3112. 27. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographicguided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004;31:308-314. 28. Ucuncu F, Capkin E, Karkucak M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain. Clin J Pain 2009;25:786-789. 29. Lee H, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: Ultrasonography-guided versus blind technique. Phys Med Rehabil 2009;90:1997-2002.
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30. Zufferey P, Revaz S, Degailler X, Balague F, So A. A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain. Joint Bone Spine 2011;79:166-169. 31. Eustace J, Brophy DP, Gibney RP, Bresnihan B, Fitzgerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997; 56:59-63. 32. Hashiuchi T, Sakurai G, Sakamoto Y, Takakura Y, Tanaka Y. Comparative survey of pain-alleviating effects between ultrasoundguided injection and blind injection of lidocaine alone in patients with painful shoulder. Arch Orthop Trauma Surg 2010;130:847-852. 33. Hsieh L, Hsu WC, Lin YJ, Wu SH, Chang KC, Chang HL. Is ultrasound-guided injection more effective in chronic subacromial bursitis? Med Sci Sports Exerc 2013;45:2205-2213. 34. Lee H, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: Ultrasonography-guided versus blind technique. Arch Phys Med Rehabil 2009;90:1997-2002.
John G. Costouros, MD, Responds I read Dr Finnoff’s response with great interest. I agree that the use of ultrasound guidance increases the ability to accurately place a needle at a target tissue. A growing body of literature supports this stance. It is also logical that direct visualization of target tissues allows for accurate needle placement. However, I disagree with several of his subsequent conclusions for a variety of reasons. First, to justify the added costs and physician time associated with utilization of this technology, it must have demonstrated utility beyond mere needle accuracy. In trying to make this claim, Dr Finnoff extols the virtues of the diagnostic utility of this technology. He does this by merely citing the studies that demonstrate the accuracy of needle placement. What he fails to consider is the accuracy and subsequent specificity of the liquid injectate. If a liquid injectate fails to stay where it is placed, then other structures are also anesthetized. Therefore, despite accurate placement of the needle, this noncontained flow results in both decreased diagnostic utility and decreased specificity of the injection. This phenomenon was illustrated in a study by Bergman and Fredericson [1]. In this study, all the subjects underwent a preprocedure MRI for comparison purposes, as well as an anatomic LMG subacromial injection. The injection was followed by immediate postprocedure MRI to determine where the injectate material actually went. The investigators demonstrated that in every procedure a 5-mL injectate tracked to many other places, including the trapezius, deltoid, and rotator cuff muscles, and that the locations varied. Therefore it is clear that soft tissue injections, such as the subacromial bursae injection in this scenario, have low specificity because of the potential spread of the local anesthetic. This result is likely different from that of joint injections, in which the joint capsule could potentially contain the injectate. This capsular containment may increase the specificity of intra-articular injections. In my opinion it may actually be intra-articular injections or injections performed
around sensitive neural structures where the real utility lies for image guidance, including ultrasound guidance. Even if concerns about the specificity of the injectate were nullified, additional concerns with the diagnostic utility of injections arise. Specifically, physicians must recognize that false-positive rates of close to 40% have been documented in the literature for single diagnostic injections [2], which further hinders the ability to interpret a positive response to these injections. Therefore, the real utility of a single diagnostic injection is likely in persons with a negative response because of the low likelihood of a target tissue not responding to a local anesthetic. With this in mind, a negative response helps effectively rule out a target tissue as a potential pain generator. Stated another way, if a tissue is injected and the patient’s pain is not relieved, then that structure is not the source of pain, thereby allowing the physician to focus on other potential pain generators. Accordingly, any injection that actually reaches the target tissue would be effective for this purpose. This raises the question of how often the injectate from an anatomic LMG subacromial bursa injection actually reaches the subacromial bursa. The aforementioned study by Bergman and Fredericson [1] found that an anatomic LMG injection of anesthetic into the subacromial bursa reached the bursa in 100% of the subacromial injections. Thus the ability to determine if a patient is a nonresponder to the diagnostic injection (and effectively rule out the subacromial bursa as the pain generator) would be present even without image guidance. In this specific case, a positive response (with or without imaging) would be difficult to interpret because of placebo rates and noncontained flow of the injectate. However, a practitioner could feel confident about a negative response (with or without image guidance), allowing his or her attention to be focused elsewhere. Therefore, the addition of ultrasound offers limited diagnostic utility for this type of injection.
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Dr Finnoff also cites several studies as evidence of the enhanced efficacy afforded by the addition of ultrasound guidance. Upon review of the 5 cited studies, serious flaws are evident in each that limit their usefulness. Three of the studies actually failed to demonstrate a clinically detectable difference of 2 points on a 10-point pain scale between groups [3-5]. One study failed to report any pain outcomes [6], and in another study a heterogeneous group of patients were injected, including those with calcific tendonitis [7]. Additionally, all studies had the flaw of lack of appropriate blinding, which is a concern given the possibility of increased placebo rates with the use of additional technology. What is still lacking in the literature is a simple study showing a clinically detectable difference in efficacy for a subacromial bursa injection on a homogenous patient population when compared with an anatomic LMG injection with sham ultrasound guidance. Additionally, Dr Finnoff cites numerous studies regarding the cost-effectiveness of ultrasound guidance. None of these studies included patients receiving subacromial bursa injections. In fact, all included either intraarticular joint injections or even carpal tunnel syndrome, which, as previously mentioned, may be an area where ultrasound guidance does offer an advantage. Lastly, an additional concern is the recent rapid increase in ultrasound utilization performed by a large number of physicians who have learned this advanced technique from weekend courses. This situation,
combined with no formal competency recognition from the American College of Graduate Medical Education, raises questions and concerns regarding the true reliability and accuracy of this technique as performed by physicians at large. Given all of these concerns, it is clear that for the scenario presented, the addition of ultrasound guidance should not be considered routine or standard practice because it does not add diagnostic utility, enhance outcomes, or result in cost-effective care. References 1. Bergman AG, Fredericson M. Shoulder MRI after impingement test injection. Skeletal Radiol 1998;27:365-368. 2. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain 1994;58:195-200. 3. Zufferey P, Revaz S, Degailler X, Balague F, So A. A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain. Joint Bone Spine 2012;79:166-169. 4. Ucuncu F, Capkin E, Karcukak M, et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain. Clin J Pain 2009;25:786-789. 5. Hsieh L-F, Hsu WC, Lin YJ, Wu SH, Chang KC, Chang HL. Is ultrasound-guided injection more effective in chronic subacromial bursitis? Med Sci Sports Exerc 2013;45:2205-2213. 6. Chen MJL, Lew HL, Hsu TC, et al. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006;85:31-35. 7. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographicguided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004;31:308-314.
Disclosure J.T.F. Mayo Clinic Sports Medicine Center, Minneapolis, MN Disclosure: nothing to disclose J.G.C. Department of Orthopaedics, Stanford University, Redwood City, CA Disclosure: nothing to disclose
D.J.K. Department of Orthopaedics, Stanford University, MC 6342, 450 Broadway St, Redwood City, CA 94063. Address correspondence to: D.J.K.; e-mail: [email protected] Disclosure: nothing to disclose
Web Poll Question For the case scenario presented in this Point/Counterpoint, which approach would you take? a. Use ultrasound guidance for shoulder injection b. Perform shoulder injection without ultrasound guidance To cast your vote, visit www.pmrjournal.org
Results of October’s Web Poll For the case scenario presented in Electrodiagnostic Testing Before Surgery for Spinal Stenosis, is routine electrodiagnostic evaluation indicated before surgical intervention? 42% - yes 58% - no
