Use of Musculoskeletal Ultrasound in the Athletes Shoulder (Normal, Abnormal and Interventions) CU Fall Symposium John Hill, DO, FAAFP, FACSM Professor, University of Colorado Friday, September 19, 2014 Disclosure Statement Newton Shoes: Physician Advisory Board MuscleSound: Inventor co-founder Physician advisor: Device & software development using ultrasound to determine muscle glycogen content. Objectives Discuss the normal ultrasound appearance of the shoulder and the individual structures Describe the AIUM standard shoulder exam Discuss the uses of dynamic imaging Review and describe interventional approaches to the shoulder Discuss evidence for and against its use Challenge Musculoskeletal ultrasound is a good diagnostic tool, but is it that good? Yes, you can U/S to: Accurately diagnose pathology and pain Precisely target injections Reduce complications and pain associated with injections and aspirations But, we must strive for excellence every time we turn on the ultrasound machine Sonography of Tendons Transverse view of biceps tendon Long axis view of biceps tendon Pathologic Phases of Tendinopathy Acute Inflammatory Response Acute fluid around tendon, tendon WNL Angiofibroblastic Changes Chronic Inflammation Early Neovascularity Neovascularity Dysfunctional Collagen Robert P. Nirschl, MD, MS Thickened dysfunctional Collagen and shortening Sonography of Shoulder Complex structure containing Muscles Tendons Bursa Bone Labrum Fixed and Dynamic evaluations Sonography of Shoulder Physician Practice Guideline is established by AIUM & ACR for the Shoulder U/S Biceps tendon Subscapularis tendon Supraspinatus tendon Infraspinatus tendon Teres minor Dynamic evaluation Sonography of Shoulder Examination of: Joint effusions Bursa effusions Comparison of contralateral side Evaluate for: Bursal thickening Loose bodies Tendon calcification Muscle & bone abnormalities Biceps Tendon- Short Axis Transverse Normal Notch view Normal transverse Biceps Tendon- Short Axis Transverse Acute Tendinopathy Chronic Tendinopathy Biceps Tendon - Long Axis Long Axis Normal Biceps LA Normal Long Axis Biceps Tendon - Long Axis Chronic Tendinopathy Fluid in tendon sheath Long Axis Acute Tendinopathy Long Head of Biceps Tendon Normal internal/external motion Normal long axis appearance Long Head of Biceps Tendon Chronic Tendinopathy Long Head of Biceps Tendon Remote long head of the biceps rupture Note empty notch with granulation tissue Long Head of Biceps Tendon Complete acute LH of Biceps rupture Note Empty sheath with effusion in Notch view Long Head of Biceps Tendon Recent long head of the biceps rupture Note empty notch with Fluid and early granulation tissue in Biceps Sheath Is there subluxation of the Long Head of Biceps Tendon? Subluxed Biceps Right Biceps sitting on lesser Tuberosity Subscapularis Tendon Short Axis view of Subscap Instruct patient to place their arm in full EXTERNAL rotation Sagittal view (Short axis) Short Axis Subscap Subscapularis Tendon Long Axis view of Subscap Instruct patient to place their arm in full EXTERNAL rotation Transverse view (Long axis) Long Axis Subscap Subscapularis Tendon Short Axis view of Subscap Instruct patient to place their arm in full EXTERNAL rotation Transverse view (Long axis) Sagittal view (Short axis) Long Axis Subscap Subscapularis Tendon 75% Subscap tear Mid long axis view NO Tendon Intact, Normal Subscap Mid long axis view Tendon intact Supraspinatus Tendon SST Normal Long Axis view Instruct patient to place their arm in INTERNAL rotation Place hand in back pocket (Long axis)45 degrees Coronal/ Sagittal SST WNL Supraspinatus Tendon SST, internal shoulder rotation SA view Instruct patient to place their arm in INTERNAL rotation Place hand in back pocket (Short axis) 90 degrees Rotation of long axis SST Short Axis WNL Supraspinatus Tendon SST with Tendinopathy Instruct patient to place their arm in INTERNAL rotation Place hand in back pocket (Long axis)45 degrees Coronal/ Sagittal (Short axis) 90 degrees Rotation of long axis SST WNL Supraspinatus Tendon-Long Axis Subacromial Bursa GT Supraspinatus, birds beak view (insertion) Supraspinatus Tendon-Short Axis WNL SAB Supraspinatus Tendon Injury Calcific Tendinopathy Full thickness tear Full Thickness tear Bursal Sided Partial thickness tear Supraspinatus Tendon Injury Acute Injury of Supraspinatus Note swelling and edema Chronic Injury of Supraspinatus Articular sided Partial thickness tear Note Echogenic and hypoechoic cystic changes Mixed echogenicity of chronic tendinopathy Rotator Cuff Ultrasonography Long history - 1977 • Accumulated research • Meta-analysis, systematic reviews • Performance – MRI, MRI-Arthro, Surgery Type SEN SPEC FT-RCT >90% >90% PT-RCT 60-75% >90% (MRI 64%/MR arthro 86%) Smith, et.al. Clin Rad 2011 Kelly, et.al. Semin Roentgenol 2009; DeJesus, et.al. AJR 2009 Best way to Diagnose a Suspected Rotator Cuff Tear? Meta analysis of 38 cohort studies for U/S (evidence B) MSK U/S used to evaluate both suspected full & partial thickness rotator cuff tears Compared with: Clinical Exam MRI Arthrography MR arthrography Diehr, et.al. J Fam Med, 55,7, July 2006 Best way to Diagnose a Suspected Rotator Cuff Tear? Full Thickness Tear Test Clin Ex U/S MRI Arth SN 0.9 SP 0.54 0.87 0.89 0.50 0.96 0.93 0.96 MR 0.95 Arth 0.96 Partial Thickness Tear Test SN Clin N Ex U/S 0.67 MRI 0.44 Arth N MR Arth In SP N 0.94 0.9 N In Diehr, et.al. J Fam Med, 55,7, July 2006 SHOULDER PAIN 33 y/o Male Partial thickness bursal sided tear Counseling USG SAB injection Rehab scapula stabilization Clinical follow-up Management and outcome of this shoulder will be different Smith, T.O., et al. (2011). “Diagnostic accuracy of ultrasound for rotator cuff tears in adults: a systematic review and meta-analysis.” Clin Radiol 66:1036-48 SHOULDER PAIN Full Thickness Tear No tear, mild tendinosis Full thickness tear Ultrasound accurately identifies Extent of retraction (to acromion) Tear size A-P width (# tendons) Ferri AJR 05; Teefey JBJS 04; Nazarian Radiology 13 SHOULDER PAIN Fatty Degeneration Fatty Degeneration US accuracy vs. MRI for SS/IS = 92.5% Reliability comparable to MRI Can be used as the primary Dx modality Wall, L.B., et al. (2012). “Diagnostic performance and reliability of ultrasound for fatty degeneration of the rotator cuff muscles.” J Bone Joint Surg 94:e83(1-9). Dynamic Motion Rotten Humeral Head Depression Poor Posture, Weak Scapula Stability Good Humeral Head Depression Good Humeral Head Depression Rotten Humeral Head Depression Poor Posture, Weak Scapula Stability Infraspinatus Tendon Instruct patient to place their arm in full INTERNAL rotation Place hand in back pocket Similar to Supraspinatus, but moved posteriorly (Long axis)45 degrees Coronal/ Sagittal (Short axis) 90 degrees Rotation of long axis Infraspinatus Tendon Long Axis appearance of IST Instruct patient to place their arm in full INTERNAL rotation Place hand in back pocket Similar to Supraspinatus, but moved posteriorly (Long axis)45 degrees Coronal/ Sagittal Normal appearance of IST Teres Minor Tendon Instruct patient to place their arm in full INTERNAL rotation Place hand in back pocket Similar to Infraspinatus, but moved Inferiorly (Long axis)45 degrees Coronal/ Sagittal (Short axis) 90 degrees Rotation of long axis Teres Minor Tendon Normal Long Axis of Teres minor Instruct patient to place their arm in full INTERNAL rotation Place hand in back pocket Similar to Infraspinatus, but moved Inferiorly (Long axis)45 degrees Coronal/ Sagittal Teres Minor Tendon Normal Short Axis of Teres minor Instruct patient to place their arm in full INTERNAL rotation Place hand in back pocket Similar to Infraspinatus, but moved Inferiorly (Short axis) 90 degrees Rotation of long axis Contralateral Comparison Long Axis Views Left SST is WNL Right SST Thickened chronic Tendinopathy AC Joint AC Joint with Moderate DJD AC Joint Normal AC Joint AC Joint AC Joint If the person is very thin, you might need standoff/interface disc AC Joint Mild DJD, but with effusion present Arthritic Changes but no effusion Injections Are guided injections Clinically Valid? Remember… Injections, whether image guided or palpation guided, require skill Inherent differences amongst physicians regardless of level of training or experience Mastery of a skill cannot be assessed by a simple number No strict definition of accuracy Damage to / injection of surrounding structures Number of attempts Confirmation method MRI Fluoro Needle placement ? Contrast? Ultrasound Dissection Arthroscopy Cadaveric model vs. clinical setting Clinical response? Group I (53) USG SA CS inj + LA gluteal inj Group II (53) USG SA LA inj + CS gluteal inj •Inclusion criteria (clinical) ≥ 18 y/o Shoulder pain x 3+ months Pain with shoulder abduction < 50% reduced GH ROM in no more than one direction Pain with 2/3: resisted abduction, ER, IR + Hawkins test 5 patients in each group had FT RCT on MRI or US Physical therapy during study not standardized Group I 8 Group II 5 History of prior shoulder injections Group I 20 Group II 18 Primary outcome measure Shoulder pain and disability index Secondary outcome measures Western Ontario rotator cuff index At 6 weeks, all outcome measures slightly favored group I Health related QOL score Active ROM Patient’s assessment of change Shoulder pain and disability index Not statistically significant Western Ontario RC index Patient’s reported change Both statistically significant No difference in AROM Pain free ROM and negative clinical tests at 6 weeks Group I 5/53 Group II 3/53 Authors conclusion My conclusions Confounders No objective diagnosis of RC disease Failed prior treatment with CS injection, chronic symptoms Effect of LA injection Lack of standardized PT No important difference in short term outcomes between USG CS and systemic CS in RC disease Watson, J., et al., Rheumatology (Oxford), 2008. 47(12): p. 1795-802. Alvarez, C.M., et al., Am J Sports Med, 2005. 33(2): p. 255-62. What are we treating??? We already know that corticosteroids are inadequate treatment for RC tendinopathy U/S Guidance may lead to small improvements in some short term outcomes EFFICACY THE PAINFUL SHOULDER Multiple studies Multiple indications Mixed results Most favor image guidance regarding short term improvements in pain and function Three systematic reviews Two felt there was adequate evidence of increased improvement in pain and function at 6 weeks to recommend USG One acknowledged increased accuracy with USG, But did not find clear evidence of efficacy to justify increased cost Conclusion appeared heavily biased by one study Sage, W., et al.,. Rheumatology (Oxford), 2012. Soh, E., et al., . BMC Musculoskelet Disord, 2011. 12: p. 137. Bloom, J.E., et al., . Cochrane Database Syst Rev, 2012. 8: p. CD009147. EFFICACY CONSIDERATIONS Available studies focus on corticosteroid injection Mounting evidence that CS may not be treatment of choice for primarily noninflammatory conditions (i.e. chronic tendinopathy) Are we asking the wrong questions? What about PRP, stem cells, Prolo, sclerosing injections, hydrodissection, tendon scraping, Tenex, etc…? Adverse effects not adequately studied in intermediate to long term Attritional effects on tendon/soft tissue SubQ fatty atrophy Tendon rupture Could these be prevented with ultrasound guidance? Is the diagnosis correct? Advantage of diagnostic and dynamic US as part of clinical exam ACCURACY GLENOHUMERAL JOINT Palpation Guided Cadaveric model, Image Guided (Sonography) 10% - 100% Cadaveric model 50% - 96% Clinical setting 93% Clinical Setting 97% - 100% Non-targeted structures injected Biceps tendon Rotator cuff ACJ Subacromial Maffulli, N., et al.,High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Phys Ther Sport, 2012. Sethi, P.M. and N. El Attrache, Accuracy of intra-articular injection of the glenohumeral joint: a cadaveric study. Orthopedics, 2006. 29(2) Rutten, M.J., et al., Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography. Eur Radiol, 2009. 19(3): p. 722-30. ACCURACY ACROMIOCLAVICULAR JOINT Palpation Guided Cadaveric model Clinical setting 40% - 72% 39% - 50% Sonographically Guided Cadaveric model 90% - 100% Clinical setting 100% -Peck, E., et al., Accuracy of ultrasound-guided versus palpation-guided acromioclavicular joint injections: a cadaveric study. PM R, 2010. 2(9): p. 817-21. -Wasserman, B.R., et al., Accuracy of Acromioclavicular Joint Injections. Am J Sports Med, 2012. -Sabeti-Aschraf, M., et al., The infiltration of the AC joint performed by one specialist: ultrasound versus palpation a prospective randomized pilot study. Eur J Radiol, 2010. 75(1): p. e37-40. ACCURACY BICEPS TENDON SHEATH Palpation only accuracy Marker placed Confirmed with sonography 5% (0 – 12%) Palpation vs US guided Type 1 (only in tendon sheath) Type 2 (inside sheath, but also tendon and surrounding area) Palpation 27% USG 87% Palpation 40% USG 13% Type 3 (only outside tendon sheath) Palpation 33% USG 0% -Gazzillo, G.P., et al., Accuracy of palpating the long head of the biceps tendon: an ultrasonographic study. PM R, 2011. 3(11): p. 1035-40. -Hashiuchi, T., et al., Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg, 2011. 20(7): p. 1069-73. Biceps Tendon Sheath Injection Diagnostic scan is performed Area of inflammation is mapped Skin is prepped and 2cc of lidocaine is infiltrated Needle is directly visualized entering tendon sheath Mapping for Injection U/S Guided Injection of Biceps Tendon U/S Guided Injection of Biceps Tendon Biceps Tendon sheath, Evidence of steroid in correct space AC Joint Injection Subacromial Bursa Injection Calcific Tendinopathy Debridement Glenohumeral Joint Injection Posterior Approach Arm held in adduction and internal rotation Approach the joint from lateral to allow the needle to follow the humeral head under the labrum into the joint Needle Post Superior Labrum Glenohumeral Joint Injection Posterior Approach Arm held in adduction and internal rotation Needle Glenohumeral Joint Injection Anterior Approach Arm held in abduction and external rotation GHJ and Labrum Glenohumeral Joint Motion & Injection Posterior Approach Shoulder moved from internal to external rotation Approach the joint from lateral to allow the needle to follow the humeral head under the labrum into the joint Glenohumeral Joint Motion & Injection Posterior Approach Shoulder moved from internal to external rotation Glenohumeral Joint Injection Adhesive Capsulitis Large volume injection To distend capsule Summary Many structures in the shoulder are superficial and can be examined accurately with MSK ultrasound Diagnostic Ultrasound can be used for accurate diagnosis and differentiation of rotator cuff tears Partial thickness tears might be seen better with MSK ultrasound than MRI There are other advantages Precisely target injections, like biceps tendon sheath You can dynamically see or not see humeral head depression You can painlessly inject the glenohumeral joint
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