Cotswold Diagnostic Clinic Specialist Local Consultant Radiology Reporting Service with Sports Clinic Diagnosis & Treatment of Orthopaedic, Spinal, Rheumatological & Sports conditions Ultrasound Guided High Volume Injections Russell Young BMUS Dec 2017 Consultant Musculoskeletal Radiologist www.cotswolddiagnosticclinic.co.uk
Introduction Lots of variation Frozen shoulder, Achilles, patellar tendon, subacromial bursa, MCL, greater trochanteric pain syndrome Volumes 10-50 ml Different injectates Water, saline, steroid, hyaluronic acid Repeat injections Difficult to do research with controls Lots of variation in study methods (case studies) Short term follow up in studies need long term FU
Frozen Shoulder (Capsulitis) Cause poorly understood Inflammatory +/- fibrotic (Dupuytren s) Limited external rotation 4 stages 1 0-3/12 synovitis (steroids?) 2 3-9/12 freezing beginning of scar formation 3 9-15/12 frozen scar formation and capsular thickening (no synovitis),!pain, "stiffness 4 15-24/12 thawing further!pain & "ROM Although self-limiting can last for years without treatment (2-4 years, up to 7)
Capsulitis rotator interval
Capsulitis - Treatment Most improvement seen in first 3/12 with mobilisation Suprascapular nerve injection (pain relief) Steroids, hyaluronic acid Steroids best in early synovitic phase multiple injections may be needed (2-3) May be a short term effect Hydrodilatation (stages 2>3) dilatation rather than rupture? (either via MUA, arthroscopic or injection) Surgical risks fracture, brachial plexus, axillary N.
Hydrodilatation technique & efficacy Fluoroscopy or ultrasound First described in 1965 in Scandinavia Injectate air, normal saline, water for injection, steroid, hyaluronic acid, lidocaine, marcain Volumes 10-40 ml (usually) - 50-100 ml Rupture usually occurs at 10-55 ml Probably don t need to rupture, as ruptures in area of weakness (some do, some don t) Follow up studies 1-4 months (most 1-2 months only) Expect 80-90% reduced pain and 60-80% improvement in SPADI (shoulder pain and disability index) score
Side effects Pain is uncommon Flushing Numbness Infection (very rare) Allergic reaction Hyaluronic acid can cause pain in s/c tissues See steroids next
Steroid Side Effects Hyperglycaemia can last for 2-5 days Hypertension Hot flushes & PM bleeding Facial flushing (10-15%) Joint flare (2-25%) Fat atrophy white skin & loss of fat Adrenal suppression lasts up to 2 weeks (HIV & Hep C anti-viral drugs) Epilepsy Zyban (anti-smoking) Cow s milk allergy methyl prednisolone (Solu Medrone)
Achilles Lifetime risk of 50% in elite distance runners 28 patients chronic tendinosis failed conservative rx Questionnaire VISA-A score 25 mg hydrocortisone, 10 ml 0.5% Marcain, up to 40 ml NS, into Kager s fat pad Rehabilitation programme (21 complied) 19 returned to sport, 10 at pre-injury level 60-70% reduction in pain and improvement in function at 4 weeks and at 7-8 months
Achilles 2 Rationale reduce neovascularity and damage nerve supply in Kager s fat pad, soft tissue release (plantaris) 20-30 ml (4 ruptures with 40 ml & compartment syn) Add in sclerosant or hyaluronic acid? Plantaris tendon if thickened inject fluid in gap (intersection sydrome) Rehabilitation programme Surgery better results with removing the plantaris tendon than removing calcification/tendinopathy Plantaris is stiffer and stronger and can compress the Achilles tendon
Patellar Tendon 22% of elite jumping sports over a career Difficult to treat 12 patients all failed conservative rx so far Questionnaire VISA-P score 25 mg hydrocortisone, 10 ml 0.5% Marcain, 30 ml of normal saline into Hoffa s fat pad Rehabilitation programme FU at 12 weeks Score improved from 45 to 65 (approximately) 1/3 returned to sport at 12 weeks Some patients no long term benefit at 9 months
Knee MCL MCL can be at ½ strength for up to 2 years post injury, with prolonged pain and instability 28 patients 19 responded IKDC subjective knee form (VAS) 2 ml of 50 mg hydrocortisone and 10 ml of 0.5% Marcain injected deep to MCL Rehabilitation programme FU at 9 months on average (2 to 27 months) 2/3 (10) returned to previous level of sport
Greater Trochanteric Pain Syndrome Steroid is thought to be less effective than home training or shock wave therapy 8 patients 6 responded 50 mg hydrocortisone & 10 ml 0.5% Marcain, injected just deep to the periosteum Rehabilitation programme FU at 1-2 months (mean 43 days) Pain & Function scores (VAS & HAGOS) Pain reduced 50% and QOL improved
Subacromial Bursa Italy and London Rationale release adhesions/scar tissue Volumes up to 50 ml used I ve used up to 20 ml Limited studies and information Some short term benefit shown in impingement syndromes from London Group
Summary High volume use up to 50 ml Shoulder hydrodilatation up to 50 ml (usually 20-40 ml) Achilles up to 30 ml (usually 15-20 ml) Patellar tendon up to 40 ml (more space) MCL and GT 10 ml Subacromial bursa up to 50 ml (aim for 20-30 ml?) Preferably don t use steroid (tendon risk & long term?) Hyaluronic acid? Needs to be with rehab programme +/- shockwave therapy Limited evidence (like a lot of MSK) Low risk if you don t use too much fluid and no steroid
Chan O, O'Dowd D, Padhiar N et al. High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil. 2008; 30(20-22): 1697-708 Morton S, Chan O, King J, Perry D, Crisp T, Maffulli N, Morrissey D. High volume image-guided injections for patellar tendinopathy: a combined retrospective and prospective case series. MLTJ. 2014; 4: 214-219 Morton S, Ghozlan A, Price J, Chan O, Morrissey D. High volume image guided injection: useful in a rugby shoulder injury? Presented at XX11 International Conference on Sports Rehabilitation and Traumatology. 20th-21st April 2013. London Morton S, Chan O, Price J, Pritchard M, Crisp T, Perry JD, Morrissey D. High volume image-guided injections and structured rehabilitation improve greater trochanter pain syndrome in the short and medium term: a combined retrospective and prospective case series. MLTJ. 2015; 5: 73-87 Drumm O, Chan O, Malliaras P, Morrissey D, Maffulli N. High-volume image-guided injection for recalcitrant medial collateral ligament injuries of the knee. Clin Rad. 2014; 69: E211-E215 Park KD, Nam H, Lee JK, Kim YJ, Park Y. Treatment effects of ultrasound-guided capsular distension with hyaluronic acid in adhesive capsulitis of the shoulder. Arch Phys Med Rehabil. 2013; 94: 264-270. Feely SM, Larson ES, Diduch DR. Adhesive capsulitis: current concepts. Ann Sports Med Res 2017; 4: 1124-1130 Baltsezak S. Management of adhesive capsulitis with landmark guided high volume steroid injections in the community based musculoskeletal clinic. Ann Rheum Dis, 2016, 72: Suppl2 SAT0511 Wybier M, Parlier-Cuau C, Baque MC, Champsaur P, Haddad A, Laredo JD. Distension arthrography in frozen shoulder syndrome. Semin Musculoskelet Radiol. 1997; 1: 251 6. Tveita et al. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomised controlled trial. BMC Musculoskeletal disorders 2008. Yoong P, Duffy S, McKean D, Hujairi NP, Mansour R, Teh JL. Targeted ultrasound-guided hydrodilatation via the rotator interval for adhesive capsulitis. Skeletal Rad, 2015; 44: 073-708 Simpson, JK, Budge R. Treatment of frozen shoulder using distension arthrography (hydrodilatation): a case series. ACO. 2004; 12: 25-35 Andren L, Lundberg B. Treatment of rigid shoulders by joint distension during arthrography. Acta Orthop Scand 1965; 36:45-53. Ongoing research at Queen Mary University of London (Tendon research)
Cotswold Diagnostic Clinic Specialist Local Consultant Radiology Reporting Service with Sports Clinic Diagnosis & Treatment of Orthopaedic, Spinal, Rheumatological & Sports conditions Russell Young Consultant Musculoskeletal Radiologist Questions? www.cotswolddiagnosticclinic.co.uk