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Ultrasound Guided Injections

A Stab in the Dark?

Sue Foley & Len Funk, 2006

What is known from the Literature?

  • There is disagreement regarding the efficacy and effectiveness of Injection Therapy in painful shoulder, (Heijiden  1996 and Green 2003). 
  • Jones (1993), Eustace, (1997) and Yamakado (2002)  have demonstrated poor accuracy of steroid placement from palpation guided injection techniques.  
  • High-resolution ultrasound has proven accurate and reliable in diagnosing a wide range of shoulder disorders compared with clinical examination, MRI and Arthrogram (Dinnes, Loveman, McIntyre and Waught 2003).
  • It's accuracy, safety, and simplicity for guiding interventional procedures has been widely described, Koski (2000), Balint (2002), Ziegler (2004), Zwar (2004), Grassi (2001) and Sofka (2000).

The Problem

  • At present variation in the administration technique of steroid injection at the shoulder exists. (Haslock 1995)
  • Clinical experience supported by evidence suggests that while some patients respond dramatically well to subacromial injection (Adebajo 1990, Blair 1996), others respond poorly and some not at all (White 1996).
  • This may be due to mis-placed injections or mis-diagnosis, since 30% of blind subacromial injections miss the bursa in expert hands (Eustace, 1997 , Sethi, 2006 , Yamakado, 2002  , Henkus, 2006 )
  • The problem is genuine uncertainty as to best practice. 

Ultrasound vs. Blind Injection of the subacromial bursa
Naredo E, Cabero F Beneyto P, Cruz A, Mondejar B, Uson J, Palop M, Crespo M.(2004).

  • Design- Randomised Cohort.
  • To determine whether blind injection or U/S guided injection is more effective as regards reduced pain & improved function in shoulder pain pts.
  • Main Results -41 pts randomised to 2 groups.
    • Ultrasound before & after interventions.  Reassessed at 6/52.
    • Outcome Measures-VAS  (p0.001) SFA  (p0.012)
    • Nocturnal Pain Active & Passive m/mts.
  • Outcome-
    • The study had clinical and statistically significant results.
    • Ultrasonography can improve the diagnosis, accuracy and ultimate effectiveness of Injection Therapy. 
    • Ultrasonography injection is superior to blind injection.
    • Ultrasonography-guided injection is to be considered whenprevious anatomically guided injection has failed.
    • Good randomisation, justified blinding measures and similar population groups provided good reliability and external validity to the study.  The results were generalisable to my clinical population.  The author acknowledged the study weaknesses and rationalised the threats to the internal validity of history and maturation.   The study had clinical and statistically significant results.

Implications for practice

  • The use of ultrasound to diagnose and to deliver the injection in shoulder pain patients is superior to blind injections to increase pain relief and shoulder function.
  • Ultrasonography can improve the diagnosis, accuracy and ultimate effectiveness of Injection Therapy.
  • Ultrasonography-guided injection is to be considered when previous anatomically guided injection has failed.
Ultrasound Guided Injection of Subacromial Bursa:
(click on image for flash video)



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