Growing Need for Musculoskeletal Injections Combined with Diagnostic Ultrasound for Guidance

Physicians from many specialties are prescribing exercise for health conditions such as: obesity, heart disease, elevated cholesterol, stress, high blood pressure and musculoskeletal disorders such as arthritis and osteoporosis. Terms such as “wellness” and “healthy lifestyle” are often used to encourage patients to improve their overall health – but what impact does exercise have on people: Those who are just becoming more active and others who have participated in strenuous activity most of their lives?Are people suffering painful results from increased activity? How can a physician be assured his treatments are working?

The population who has not been active begins to move and can experience new aches and pains that are unfamiliar while the healthier groups may reinjure or damage a weakened area. New activities, strenuous movements, repetitive motion and wear and tear can result in painful joints and other musculoskeletal injuries. Stress on our joints can lead to osteoarthritis resulting in significant pain as a lack of healthy cartilage and joint fluid cause bone to rub on bone at the joint surfaces. As the population ages, osteoarthritis is a more common issue.

Many orthopedic and musculoskeletal injuries can impede the goals to maintain this sought after active lifestyle. Physicians aim to manage patients’ injuries so that they can maintain mobility and participate in the activities that they enjoy for as long as possible. By doing so, patients are happy and more comfortable and they may continue to experience the proven benefits of exercise.

A variety of treatments, including biomechanics, posture, activity modifications, flexibility, and supporting muscle strength are prescribed by physicians to heal musculoskeletal injuries and joint pain. However, if a patient does not respond to focused physical therapy, rehabilitation or supporting muscle strength alone, a therapeutic injection may be the next step. Various nerve blocks, intra-articular injections, trigger point and muscular injections are all used to reduce pain in patients.

Joint injections are a minimally invasive treatment option used to relieve pain caused by inflammatory joint conditions such as rheumatoid arthritis, tendonitis, synovitis (inflammation of the lining of the joint), bursitis and gout.1 These inflammatory conditions often respond to corticosteroid and/or local anesthetic medication directly into the joint or into the soft tissue next to the joint (bursa) to reduce the inflammation and provide pain relief. Joint injections can be used to relieve pain in any joint in the body:

• Knee (knee joint, Baker's cyst) 
• Shoulder (rotator cuff/subacromial bursa, acromioclavicular joint, shoulder/glenohumeral joint, biceps tendon) 
• Ankle 
• Elbow (lateral epicondyle, medial epicondyle, elbow joint) 
• Wrist (thumb/first CMC joint , carpal tunnel, trigger finger, DeQuervain's tenosynovitis) 
• Thumb 
• Hip (hip joint, bursa/greater trochanter, piriformis, sacroiliac joint) 
• Large toe 
• Facet joints of the vertebrae

There are several medications, such as corticosteroids or viscosupplementation (Synvisc, Supartz or Euflexxa), used to reduce inflammation and minimize pain, when injected into the affected joint. This medication only affects the targeted area and does not usually cause side effects. Joint injections are administered under local anesthesia and only cause mild, brief discomfort for patients.2 Botox (a toxin produced by bacteria) paralyzes the muscle into which it is injected. This paralysis and resultant relaxation of the muscle is what reduces the pain, as the pressure on nerves associated with the musculature is relieved. The distinct advantage of BOTOX™ therapy is its ability to treat a specific target area. Facet joints are located on either side of the vertebrae and give the spine its flexibility. These joints, like other joints in the body, can be a great source of pain when they become irritated or inflamed (usually from an initial injury or from arthritic conditions). A facet joint injection serves as both a diagnostic tool and a type of treatment. After the injection, if the patient’s pain subsides, then the doctor knows that the facet joint is the source of the pain. As a result of any pain injection, reduction in pain allows the patient to participate more fully in physical therapy and therefore continue to move towards that active lifestyle.

Many of the structures, or targets, that we are aiming for during any of the above musculoskeletal injections, are very specific and can be only millimeters in size. Accuracy with injections is important when the outcome is to relieve or reduce the patient’s pain.

Ultrasound Guidance for MSK Injections

Traditionally, musculoskeletal (MSK) injections have been performed based on anatomical landmarks. That is, that the physician feels for specific bones, muscles, or tendons and then injects into the desired area. This is known as, a ‘blind’ technique because there is no way of definitively knowing where the tip of the needle is or where the injection is going. Many providers have been using this landmark or blind technique for a long time and are confident with their skill level.

However, MSK Ultrasound has become extremely popular not just for diagnostic imaging of musculoskeletal structures, but the application of ultrasound in pain medicine is a rapidly growing imaging modality in interventional pain management.

Ultrasound imaging, uses high frequency sound waves, and provides direct visualization of various soft tissues of the body. As a result of the improved resolution of ultrasound images in the last 5 years, nerves and nerve tissue is well visualized. Bone edges are also identified with ultrasound so that joint spaces are quite obvious. The needle is easily recognizable and ultrasound imaging provides real-time needle advancement to the target area. The needle, and needle tip, can be seen on the ultrasound screen and the precise location of the injection is assured. If using the landmark technique, the needle tip delivering the medicine is not appropriately or definitively placed, the physician cannot be sure if the needle reached the appropriate site with the medicine, or if the medicine was not appropriate for the patient’s ailment. Exact location of injection is not only important for the effectiveness of the injection itself, but also for the benefit of the patient and for the feedback to the physician. If the physician knows that the injection has been placed appropriately and the injection does not improve the symptoms, then the physician knows that he/she must look for another cause of the pain described by the patient.

In addition to providing the physician with more accurate injection aim and improving patient care, currently, there is reimbursement for using ultrasound to visualize the injection site. This amount is directly related to the assistance this imaging technique provides the physician for confidently knowing that the medicine is delivered exactly to the target and point of pain within the patient.3

Ultrasound also helps patients recognize (with some direction) what they are looking at. Having the patient understand and see the location allows them to become more involved with their own therapy, giving the physician better final results. In addition, the physician can take pre and post injection images to monitor the progress of the injection treatment. For physicians new to ultrasound, there is a learning curve to being able to utilize the ultrasound effectively, as well as the capital expense required, however, vital accuracy is added to each injection and with an average practice, the ultrasound system pays for itself in about 6 months.

Another benefit of using ultrasound imaging is that it does not expose the patient and healthcare provider to radiation risks. As an imaging modality, the ability of the ultrasound system to generate a real-time image and real-time loops, or movies, is a benefit to diagnoses. The procedure may be documented, but also the actual motion that patient goes through to demonstrate their pain or area of pain may be documented. Impingement, for example, can be visualized as it occurs on an ultrasound loop.

Justification for Ultrasound Guidance

Several documented studies have examined the ‘actual’ accuracy of this technique. Following are examples of those studies providing proof that ultrasound guided injections yield better patient results. The studies conducted compared the efficacy of blindly guided (landmark technique) versus ultrasound-guided injections. The results have shown that ultrasound-guided injections are associated with significantly less procedural injection pain, provide increased pain relief lasting for a longer duration than with landmark guided injections. The improved performance of ultrasound-guided injections leads to a decrease in health care costs per patient, while improving patient care.4

One study conducted by Cunnington et al, performed corticosteroid injections using needle guidance with diagnostic ultrasound and clinical examination (CE) in 184 patients with inflammatory arthritis. Treatment outcomes were measured with serological markers of inflammation and patient assessment questionnaires. They found that Corticosteroid injection in the joints of patients with inflammatory arthritis resulted in significant alleviation of symptoms and improvement in functional status. Ultrasonography (US)-guided injections are significantly more accurate than (CE)-guided injections.8 (21) US-guided injections were accurate in 83% of patients, compared with 66% of patients who had CE-guided injections. All joints showed increased accuracy using ultrasound guidance, particularly the shoulder, elbow and ankle. Importantly, this greater accuracy of US-guided injections held true regardless of the physician’s level of experience—junior trainees were more precise with US than senior physicians were with CE. Joint function at 6 weeks was better in the US group than in the CE group.5

Ultimately, the study determined that ultrasonography (US)-guided injections are significantly more accurate than clinical examination (CE)-guided injections.6

Matthieu et al, performed a four image-guided injection technique (Floro, anterior and posterior approach, US anterior and posterior approach) and compared several and certain variables. All were successful in injection of contrast material into the glenohumeral joint. A successful first attempt significantly occurred more often with US (94%) than with fluoroscopic guidance (72%). Matthieu et al, encourage US-guided injections and especially the anterior approach, because in this study it was significantly less time consuming, more successful on the first attempt, can be performed with less patient discomfort and obviates the need for radiation and iodine contrast. With US guidance mean room, procedure and radiologist times were significantly shorter.7

Sibbet et al performed 148 corticosteroid injections for painful joints (100 rheumatoid arthritis and 48 with osteoarthritis) and compared palpation (landmark technique) with sonographic guidance. Pain was measured with the standardized and validated Visual Analog Scale (VAS) pain score.8
They found that the patents that were injected using ultrasound guidance had significantly less pain during the injection and better outcomes than those managed conventionally. Injection pain was reduced by 43%, and absolute pain scores at 2 weeks were reduced by 58.5%. Pain was decreased by 75%, which was significant, for the ultrasound guidance injections. Sonographic guidance had better response rates as there was a 25.6% increase in responders and a 62% decrease in non-responders. Even the amount of fluid withdrawn was greater in the ultrasonography group.9

Conclusion

Study examples presented here have compared the traditional, and still widely used, landmark technique to using ultrasound needle guidance. Together these studies have shown that ultrasound-guided injections are associated with significantly less procedural injection pain and provide more pain relief. As individuals embrace wellness and increase their activity level with strenuous movements, repetitive motion and wear and tear the result may be painful joints and other musculoskeletal injuries, physicians will be looking for ways to assist in enabling the healthy lifestyle while decreasing a patient’s pain. Beyond physical therapy and other initial techniques to help patients, therapeutic injections are becoming a necessary part of pain management in musculoskeletal injuries. Incorporating diagnostic ultrasound imaging is a tool that improves physician confidence with this form of treatment resulting in better patient care.

Sources:
1,3-Ultrasound Guided Joint Injection Advanced Pain Management Center Columbus, Ohio

2-Joint Injection Consumer Information for Health Professionals

4-Access Sports Medicine & Orthopedics, website Kevin D. Heaton, DO

5,6-Cunnington J, Marshall N, Hide G, et al, Freeman Hospital and Newcastle University, Newcastle upon Tyne, UK, and other centers. A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis Rheum. Sept 2010;62:1862-1869. 21

7-Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography
Matthieu J. C. M. Rutten,1 James M. P. Collins,2 Bas J. Maresch,3 Jacques H. J. M. Smeets,4 Caroline M. M. Janssen,1 Lambertus A. L. M. Kiemeney,5 and Gerrit J. Jager1
1Department of Radiology, Jeroen Bosch Hospital, Nieuwstraat 34, 5211 NL ‘s-Hertogenbosch, The Netherlands Department of Radiology, Medical Centre Leeuwarden, H. Dunantweg 2, 8934 AD Leeuwarden, The Netherlands Department of Radiology, Hospital Gelderse Vallei, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands Department of Radiology, Slingeland Hospital, Kruisbergseweg 25, 7009 BL Doetinchem, The Netherlands Department of Epidemiology and Biostatistics, Radboud University Nijmegen Medical Centre, Geert Grooteplein Noord 21, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands Matthieu J. C. M. Rutten, Phone: +31-73-6992000, Fax: +31-73-6992601, Email: m.rutten@jbz.nl . Contributor Information. Corresponding author. Received June 30, 2008; Accepted September 19, 2008. 22

8,9-Sibbitt WL Jr, Peisajovich A, Michael AA, et al, University of New Mexico Health Sciences Center, Albuquerque, and other centers. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36:1892-1902 23