Ultrasound-Guided Joint Injection€¦ · structures- shoulder, knee, ... • Ultrasound guided...

Ultrasound-Guided Joint Injection

Jason Matuszak, MD, FAAFP

Mark Mirabelli, MD, FAAFP

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians

for educational purposes only. Please note that medical information is constantly changing; the

information contained in this activity was accurate at the time of publication. This material is not

intended to represent the only, nor necessarily best, methods or procedures appropriate for the

medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion

of the faculty, which may be helpful to others who face similar situations.

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this material and for all claims that might arise out of the use of the techniques demonstrated therein

by such individuals, whether these claims shall be asserted by a physician or any other person.

Physicians may care to check specific details such as drug doses and contraindications, etc., in

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DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with

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All other individuals in a position to control content for this session have indicated they have no relevant financial

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The content of my material/presentation in this CME activity will not include discussion of unapproved or

investigational uses of products or devices.

Jason Matuszak, MD, FAAFPChief, Division of Sports Medicine, Excelsior Orthopaedics, Amherst, New York; Clinical Assistant Professor,

University at Buffalo Jacobs School of Medicine and Biomedical Sciences, New York

Dr. Matuszak earned his medical degree at the State University of New York (SUNY) Upstate Medical

University in Syracuse. He completed his family medicine residency at St. Joseph’s Hospital in Syracuse

and a sports medicine fellowship at the University of Hawaii at Manoa, Honolulu. A family physician and

sports medicine physician who is board certified in clinical informatics, he is the founder and director of The

Sports Concussion Center at Excelsior Orthopaedics, Excelsior Sports Medicine’s STRIDES program for

running and endurance medicine, and a musculoskeletal ultrasound program. He serves as a school

physician for Williamsville Central School District and a team physician for 12 local high schools. He has

also worked as a team physician for the Buffalo Bisons (AAA affiliate of the Toronto Blue Jays) and the

Western New York Flash of the National Women’s Soccer League, and as a volunteer physician for the

Ironman World Championship, the U.S. Olympic Committee, and USA Hockey. In addition, he has helped

develop team physician consensus conference guidelines and clinical practice guidelines for

musculoskeletal conditions. Dr. Matuszak is speaker of the Congress of Delegates for the New York State

Academy of Family Physicians and chair of the Physicians Advisory Council to the P2 Collaborative of

Western New York and HEALTHeLINK, western New York’s regional health information organization.


Team Physician, St. John Fisher College (Rochester, N.Y), the Rochester Knighthawks, and

the State University of New York, Geneseo; Ringside Physician, New York Athletic

Commission

Dr. Mark Mirabelli completed the Primary Care Sports Medicine Fellowship at the Cleveland

Clinic Foundation, where he was a team physician for the Cleveland Browns, Cavaliers, and

Indians as well as treating collegiate athletes at Cleveland State University, John Carroll

University, and several high schools. He completed his family medicine residency at the

University of Michigan, where he served as Chief Resident, and graduated from Cornell

University and New York Medical College. He lectures regularly on sports medicine and has

written several journal articles and textbook chapters focusing on men's health, sports

medicine, and office-based musculoskeletal procedures. Dr. Mirabelli also maintains a small

primary-care practice at Highland Family Medicine in addition to managing the entire spectrum

of musculoskeletal problems in his practice at University Orthopedics Associates, Rochester.

Learning Objectives

1. Discuss the basic principles of ultrasound imaging, equipment,

functionality, aseptic technique and injectate selection for ultrasound-

guided pain procedures.

2. Develop scanning techniques to optimize musculoskeletal windows for

ultrasound guided injections.

3. Practice joint injection techniques using models.

4. Establish appropriate billing and coding protocols for performing

billable injections.

Class outline

• Knobology/Reading ultrasound basics

• Injection applications

• Knee

• Shoulder

“Orthopedic” Uses of Point of Care

Ultrasound (POCUS)

• Diagnostic

• Guidance for procedures


Ultrasound (POCUS)• Diagnostic

– Assess acute or chronic injuries or diseases• Muscle/Tendon – Strain/tear, tendonopathy

• Ligament – Sprain/tear, laxity/instability

• Bone – Fracture, cortical thickening/callus

• Nerve – Laceration, entrapment, neuroma

• Joint/capsules/synovium – Effusion, Avulsion, hypertrophy/hyperplasia (+rheumatic)

– Masses – solid/cystic

• Guidance for procedures


Ultrasound (POCUS)• Diagnostic

• Guidance for procedures– Injections/aspirations

• Joint –

• Tendon sheath -

• Bursae

• Nerve

– Novel procedures• Needle tenotomy

• ?Surgical interventions

What’s the data?

• Across the board – All are more accurate• AMSSM Position: USGIs are more accurate than LMGIs (SORT A).

– Major joint• Glenohumeral, Femoral-acetabular, Knee, Sacroiliac

– Intermediate joint• Sternoclavicular, Acromioclavicular, Elbow, Wrist, Ankle, Midfoot

– Small joint• Intercarpal/carpometacarpal, Interphalyngeal

– Tendon Sheath

– Nerve

Finnoff, CJSM 2015

What’s the data?

• Across the board – Some are more Efficacious• AMSSM Position: USGIs are more efficacious than LMGIs (SORT B)

– Major joint• Glenohumeral, Femoral-acetabular, Knee, Sacroiliac

– Intermediate joint• Sternoclavicular, Acromioclavicular, Elbow, Wrist, Ankle, Midfoot

– Small joint• Intercarpal/carpometacarpal, Interphalyngeal

– Tendon Sheath

– Nerve

What’s the data?

• Some might… Save a surgery?

– Paralabral cyst aspiration

– Calcific tendonitis debridement

– Platelet Rich Plasma

– Adhesive capsulitis

What’s the data?

• May be better than fluoroscopy?– Radiation

– Contrast

– Accuracy

– Time for procedure

– Patient comfort

– Cost

– Location (office vs radiology facility or hospital)

– Diagnostic information in addition to location

Knobology/Reading Ultrasound

Jason M Matuszak, MD FAAFP

Chief of Sports Medicine, Excelsior Orthopaedics, Buffalo, NY

Principles of ultrasound

Infrasound<20 Hz

Audible range20 Hz to 20 kHz

Ultrasound>20 kHz

Whales, elephants, Rhinoceros

Humans Dogs, dolphins, bats, mice

https://commons.wikimedia.org/wiki/File:Sonar_Principle_EN.svghttps://commons.wikimedia.org/wiki/File:UsMachTxPhoto.jpg

Machine controls

• On-Off

• Presets

• Depth

• Focus

• Gain – overall

• Time Gain Compensation

• Freeze

• Frequency

• Measuring tools

• Color Doppler

• Power Doppler

• Spectral Doppler

• M Mode

• Save/Clips

Science of Ultrasound

• Reflection of Sound

– Angles make a difference –anisotropy

– Signal attenuates as tissue bends away

– Direction of the probe

– Contact and fluid transmission

• Frequency / Penetration –probe selection

Graphics and pictures this page: Matuszak 2018

Focal Zone

• Multi-beam technology

• Focal depth is sometimes

adjustable

Focal Zone

Near Zone

Far Zone


Probe Basics


Scanning Planes

• To body axis or to target structure

– Transverse

– Longitudinal

– Sagittal

– Coronal

– Oblique

Probe Maneuvers

Heel-Toe ToggleGraphics and pictures this page: Matuszak 2018

Probe Maneuvers

Long axis slide Short axis slideGraphics and pictures this page: Matuszak 2018

Terminology

• Anechoic

• Hypoechoic

• Isoechoic

• Hyperechoic


Ultrasound Interpretation

Bone Tissue FluidGraphics and pictures this page: Matuszak 2018

How to look at an ultrasound picture

Muscle

Tendon

Subcutaneous fatSkin

Bone

Transition Slide

Equipment

• Gloves (sterile vs semi vs clean)

• Needles

• Antiseptic

• Povidone-iodine or chlorhexadine or alcohol

• Syringes

• Collection tubes (if aspirating) /cap

• Gauze and Bandages

Needle and Syringe• Small joint / trigger point : 1 cc

• Medium joint: 3 cc

• Large joint : 5-10 cc

• Aspiration: 20-60 cc

• Use appropriate gauge

• 18 gauge for aspiration

• 27 gauge for skin anesthesia and fingers

• Use needle long enough (minimum length)

• 5/8 inch- finger

• 1 inch - elbow

• 1 1/2 inch - Shoulder, knee

• 3 inch spinal - Hip trochanter

Needle Selection

• Better to have a slightly longer needle than needed

than one that is too short

• Consider blunt or minimal bevel for nerve injections

• Echogenic needles can be used (higher cost, better

reflectivity)

– Modern US needle guidance packages may make

unnecessary

30

What to inject?

• Anesthetic

• Corticosteroid

• Hyaluronic acid

• Prolotherapy / sclerosing solutions (dextrose, etc)

• Other: PRP / autologous blood / BMAC / Adipose

Probe specifications

• A 12 MHz transducer has very good resolution, but cannot penetrate

very deep into the body

– Use high frequency probe / linear (8-18 MHz) for more superficial

structures- shoulder, knee, elbow

• A 3 MHz transducer can penetrate deep into the body, but the

resolution is not as good

– Use low frequency probe / curvilinear (1.5 -5 Mhz) for deeper

structures – hip, sacroiliac

Patient and examiner positioning

• Patient, examiner and screen all in line

• Patient problem area maximally exposed –patient may be supine,

prone, seated in chair or rotating stool

• Examiner standing, seated in chair or stool - don’t bend or squat

• Use proper ergonomics

– Rest hand on patient

– Neck and back of examiner upright

– Relax hand and wrist

33

Process of Injection

• Use adequate sterile gel- try gel standoff if needed

• Place transducer on skin and find “home” anatomy

• Subtle hand motions translate to significant changes on screen

• Adjust frequency, depth, gain, focus (not all settings may be available)

• Obtain optimal image of injection site BEFORE introducing the needle

• Use image guidance mode /software if available

• Introduce needle at appropriate angle and adjust image guidance software

(shallow, medium, steep angle)

• Make further adjustments with probe position or needle- not both at same

time

34

Needle Positioning

• Needle Position:

In plane

-needle parallel and in plane with

transducer

-entire needle shaft and tip as

well as target structure are

visualized throughout

interventionMalanga et al, Atlas of Ultrasound-Guided Musculoskeletal Injections. 2-6

Needle positioning

• Needle position:

Out of plane

- transducer oriented

perpendicular to needle

- needle only visualized when

in the field of view

Out of plane approach

Malanga et al, Atlas of Ultrasound-Guided Musculoskeletal Injections. 2-6

Can’t find the needle?

• Advance needle slowly

• Wiggle the needle

• Inject small amount of fluid

• Pull back and reposition or reangle

• Hold needle and sweep the probe

• Still problems? Start over or abort

37

Summary Practice

Recommendation Slide

• Ultrasound guided injection or aspiration of various soft tissues and joints is

more accurate than clinically guided injections and may reduce

complications

• Imaging tool – Must have the knowledge to understand how the image is

formed

• Obtain and use supplies and instruments that fit the purpose

• Optimize the best image of the injection site first – know the anatomy

• Make fine adjustments of the probe OR needle separately to improve the

image

Questions

Selected References

European Society for MSK Radiology, Technical Guidelines V Knee. 2010. Available at

https://essr.org/content-essr/uploads/2016/10/knee.pdf

The association for medical ultrasound (AIUM) – AIUM Practice Parameter for the Performance of a

MSK US Exam. 2017. Available at https://www.aium.org/resources/guidelines/musculoskeletal.pdf

Fundamentals of MSK Ultrasound 3rd Ed. Jacobson, Jon. A. 2017


https://www.aium.org/resources/guidelines/musculoskeletal.pdf

Ultrasound-Guided Shoulder

InjectionsJason M Matuszak, MD FAAFP

Chief of Sports Medicine

Excelsior Orthopaedics

Matuszak Rule to Ultrasound-Guided

Injections

• There are only 2 injections to learn – the in-

plane (long axis) injection and the out-of-plane

(short axis) injection – then the only thing that

changes is the target structure.

– If you can find the target, and a safe path to it, you

can inject it

Matuszak Rule to Ultrasound-Guided

Injections


Injection basics

• Overall risk-benefit of local corticosteroid injection for long

term outcomes remains unclear

• Effect of local anesthetic on tissue is unclear

• Other injectates (PRP, prolotherapy, MSC) remain

experimental

• Using ultrasound for guidance does not change sterility level

of technique

• Injections into spaces or potential spaces should always flow

easily!

Injection basics

• Make sure you can reach your target structure

• Many different approaches to every injection

– We’ll teach one, but you can experiment

• All injections are more accurate with imaging guidance (Finnoff CJSM 2015)

– Not all may be more efficacious

– Average change in cost is about $40

– Procedures with guidance may take longer

Clinical Case #1

• Hey Doc – “I was raking my leaves for about 2 hours on Friday and by Sunday, I could lift my arm over my head. Can you inject me or something?”– 44 year old male with right shoulder pain

– Started after raking

– Pain is reproduced with abduction

– No strength deficit

– Negative drop-arm test

– Positive Neer and Hawkins

– X-rays are negative

Subacromial/Subdeltoid Bursa

• Indications for injection

– Subacromial “bursitis”

– Subacromial impingement

– Rotator cuff tendonitis

– Calcific tendonitis or bursitis

• Calcium Pyrophophate


• Evidence– Cochrane review 2012 – no added benefit from

image-guided injections• no difference at 1 or 2 weeks

• Discounted benefit at 6 weeks due to heterogeneity

– Wu 2015 – Meta-analysis showed improvement at 6 weeks of:

• Pain

• Functional Scores

• Abduction degrees


• Is ultrasound-guidance indicated?

– +/-


• Positioning and Landmarks

– Lateral approach

• Seated

• Palpate lateral aspect distal acromion

https://commons.wikimedia.org/wiki/File:Shoulder_joint_back-en.svg


• Pertinent ultrasound landmarks– Lateral

approach• Biceps

tendon

• Greater tuberosity

• AcromionGraphics and pictures this page: Matuszak 2018

Gre

ater

Tu

bero

sity

Less

er

Tube

rosi

ty

Supraspinatus Subscapularis


• Pertinent ultrasound landmarks– Lateral

approach• Biceps

tendon

• Greater tuberosity

• AcromionGraphics and pictures this page: Matuszak 2018


• Confirmation

– Should see fluid motion effect filling bursal sac

– Injection should flow easily

Clinical Case #2

Hey Doc – “My shoulder hurts every time it’s cold and damp and it’s really stiff in the morning when I wake up. Can you inject me or something?”

– 84 year old female with right shoulder pain

– Progressively worse over several years

– Pain is reproduced with all active range of motion

– Palpable grinding and crepitus with motion


– X-rays are show severe GH arthritis

Glenohumeral Joint `

• Indications for

injection

– GH arthritis

– Frozen

Shoulder

– Labral tearBlausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of

Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436

https://en.wikiversity.org/wiki/WikiJournal_of_Medicine/Medical_gallery_of_Blausen_Medical_2014

https://en.wikipedia.org/wiki/Digital_object_identifier

https://doi.org/10.15347/wjm/2014.010

https://en.wikipedia.org/wiki/International_Standard_Serial_Number

https://www.worldcat.org/issn/2002-4436

Glenohumeral Joint

• Evidence

– More accurate (Finnoff CJSM 2015)• US guided GH injection 91-100% accurate

• Landmark guided GH injection – 64-73% accurate

– More effective (Lee Arch Phys Med Rehabil2009)

• Pain intensity, range of motion, and shoulder function score

Glenohumeral joint


– YES

Glenohumeral Joint

• Positioning and

Landmarks

– Seated facing

away

– Palpate

scapular spinehttps://commons.wikimedia.org/wiki/File:Shoulder_joint_back-en.svg

Glenohumeral joint

• Pertinent ultrasound landmarks– Posterior

approach• Scapular Spine

– Posterior RC MTJ

• GlenohumeralJoint


Glenohumeral joint


approach• Scapular

Spine



Glenohumeral joint


approach• Scapular Spine


– Humeral head/capsule


Glenohumeral Arthritis

• Confirmation

– Should see fluid motion in the space under

the joint capsule and around humeral head

– Injection should flow easily

Clinical Case #3

• Hey Doc – “I’ve noticed that I have this lump at the point of my shoulder that aches and it’s worse when I carry my purse on this side. Can you inject me or something?”– 46 year old transgender female with right shoulder pain

– Notices with changes in weather and carrying purse on this side

– Pain is reproduced with abduction and overhead weightlifting

– Feels crepitus and grinding when reaching across chest to the opposite shoulder

– No strength deficit


– X-rays show ac joint arthritis

Acromioclavicular Joint

• Indications for

injection

– AC joint

arthritis


• Evidence– More accurate

• 93.6% USGI versus 68.2% LMGI (Aly BJSM 2015)

– More effective• +/- one small study (20 participants) showed no benefit

(Sabeti-Aschraf Eur J Rad 2010)

• + benefit in another study of 100 patients (Park Pain Phys 2015)

– Better pain

– Better function



– YES


• Positioning and Landmarks

– Superior or Anterior approach

– Short Axis usually By OpenStax College [CC-BY-3.0

(http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons


• Pertinent ultrasound landmarks– Cranial from

Bicipital Groove

– Lateral from the clavicle

Graphics and pictures this page: Matuszak 2018 Gre

ater

Tu

bero

sity

Less

er

Tube

rosi

ty

Supraspinatus Subscapularis


• Pertinent ultrasound landmarks– Cranial from

Bicipital Groove

– Lateral from the clavicle



• Confirmation

– Fluid motion signal deep to the joint capsule

– Ease of injection

Selective References

• http://www.aium.org/usinteractive/index.ht

ml#

• https://www.essr.org/subcommittees/ultras

ound/

http://www.aium.org/usinteractive/index.html

https://www.essr.org/subcommittees/ultrasound/

Ultrasound Evaluation of the Knee

Audience Response #1

A 57 year old male has fallen on his knee and is seen the same day. Examination reveals decreased range of motion and 2/5 quadriceps strength. Moderate tenderness is present in the suprapatellar knee, a small effusion is noted . No other abnormaltiesare noted. Initial xrays are negative. Ultrasound imaging of which structure will be diagnostic?

1. Quadriceps tendon

2. MCL

3. ACL

4. Hamstring tendon

5. Pes Anserine

Audience Response #2:A 28 year recreational basketball player twists her knee during a game. She feels a pop and has limited ability to walk with significant swelling. Which of the following could NOT be seen on diagnostic US of this knee?

1. Loose body in joint

2. LCL sprain

3. Knee effusion

4. Medial meniscal root tear

5. Patellar tendon tear

Audience Response #3:A 56 year old female is complaining of worsening knee osteoarthritis. You recommend an injection of the knee. Which of the following injuries is not an indication to perform an ultrasound guided injection of the knee?

1. Morbid obesity

2. Failed previous clinically guided attempt

3. Decreased pain

4. Increased aspirate amount

5. Clinically inaccessible joint

Knee Anatomy

• Sprains – ligament

• Strains – musculotendonous

• Fractures

• Dislocations / subluxations

• Cartilage injuries – meniscal vs

chondralBy Kari Stammen, via Wikimedia Commons

Illustration from Anatomy & Physiology, ConnexionsWeb site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013via WikiMediaCommons

http://cnx.org/content/col11496/1.6/

Differential Diagnosis

• Meniscal tears

• Fractures• Supracondylar femur• Patellar• Tibial plateau

• Chondral / Osteochondral lesions

• Dislocations / subluxations• Tibio-femoral• Patello-femoral

• Soft tissue Contusions / hematomas

• Lacerations, abrasions

• Ligament or capsular sprains• ACL, PCL, LCL, MCL

• Bursitis• Pre-, Infra- patellar • IT band, pes anserine

• Muscle and tendon strains• Quadriceps• Hamstring• Pes anserine

By Hellerhoff (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

MSK US Knee Protocol

• Patient in supine position with bolster

– Scan long and short axes suprapatellar

– Trochlear view

– Infrapatellar long axis

– Medial and Lateral joint lines long axis

• Patient in prone position

– posterior knee long and short axes

Anterior Knee Long Axis

MSK US Knee, Mark H. Mirabelli, MD

European Society of MSK Radiology, MSK US Technical Guidelines, V. Knee

Anterior Knee Short Axis



Trochlear View


Infrapatellar Long axis



Medial joint line – long axis



Lateral joint line – long axis


Posterior knee


Ultrasound Guided Injection

• Lateral suprapatellar approach

Summary Practice

Recommendation Slide

• MSK US of the knee is a useful adjunct for

diagnosing many conditions

• Assessment of effusion, tendons and ligaments

can be rapidly performed

• Ultrasound guided injection or aspiration of the

knee can be done at the suprapatellar lateral

portal, the pes anserine and the posterior knee

(Baker’s cyst)

Questions

Selected ReferencesEuropean Society for MSK Radiology, Technical Guidelines V Knee.

2010. Available at https://essr.org/content-

essr/uploads/2016/10/knee.pdf

The association for medical ultrasound (AIUM) – AIUM Practice

Parameter for the Performance of a MSK US Exam. 2017.

Available at


Fundamentals of MSK Ultrasound 3rd Ed. Jacobson, Jon. A. 2017



Contact

• Mark H. Mirabelli, MD, FAAFP

• [email protected]

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