Palpation-guided Injection Research Articles

Territories of Nerve Endings of the Medial Plantar Nerve within the Abductor Hallucis Muscle: Clinical Implications for Potential Pain Management.

This study aimed to elucidate the intramuscular distribution pattern of the medial plantar nerve and determine its motor nerve ending territories within the abductor hallucis muscle using modified Sihler's staining and external anatomical landmarks. The study included 40 specimens of the abductor hallucis muscle (13 men and seven women) from formalin-fixed (ten cadavers) and fresh cadavers (ten cadavers), with a mean age of 77.6 years. The entry point of the medial plantar nerve into the muscle was examined, followed by Sihler's staining to analyze the intramuscular distribution pattern and motor nerve ending location within the abductor hallucis muscle. Ultrasound- and palpation-guided injections were performed to verify the applicability of motor nerve ending location-based injections. The areas with the highest concentrations of nerve entry points and nerve endings were identified in the central portion of the muscle. Ultrasound- and palpation-guided injections were safely positioned near the densest nerve ending region of the muscle. These detailed anatomical data and injection methods would be beneficial for proceeding with safe and effective injection treatments using various analgesic agents to alleviate abductor hallucis muscle-associated pain disorders.

Ultrasound versus palpation-guided corticosteroid injection for de Quervain disease: A randomized controlled trial.

Corticosteroid injection effectively treats de Quervain disease, and due to the high prevalence of the intracompartmental septum in the first extensor compartment, ultrasound guidance improves injection accuracy. To compare the effectiveness, adverse events, and the recurrence rate between ultrasound-guided and palpation-guided injection in patients with de Quervain disease. Prospective, single-blind, randomized controlled trial. Rehabilitation department of a private teaching hospital. We enrolled 49 patients, ≥20 years of age, clinically diagnosed with de Quervain disease based on their medical history and physical examination. Patients were randomized into two groups: ultrasound-guided and palpation-guided injection. Both groups received a mixture of 10 mg triamcinolone acetonide (10 mg/1 mL) and 0.3 mL 1% lidocaine. The primary outcome measure was the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score at 1 week. The secondary outcome measures were visual analog scale for pain (pain VAS) score, patient satisfaction, and adverse events or complications from the interventions at 1 week, 3 months, and 6 months. Both groups showed improvement over time in QuickDASH scores and pain VAS (p < .001); however, no statistically significant differences were noted between the groups for either QuickDASH scores (p = .22) or pain VAS (p = .30). In addition, no statistically significant differences were found between the groups in terms of patient satisfaction (p = .76) and adverse events (p = .47, .33, .58) at the 1-week, 3-month, and 6-month follow-ups. Both ultrasound-guided and palpation-guided injections effectively treated de Quervain disease. During a 6-month follow-up, there were no statistically significant differences between the groups in pain relief, upper limb function, or patient satisfaction. However, the palpation-guided group showed a tendency for more recurrence and skin side effects.

Outcome of Local Corticosteroid Injection by Ultrasound- versus Palpation-Guided Technique in Plantar Fasciitis

Background: Plantar fasciitis is a common cause of heel pain. Conservative treatment is often effective, but in many cases, invasive procedures may be required. Local corticosteroid injection is the most frequently used invasive technique and can be given under ultrasound (USG) or palpation guidance. We sought to compare the outcome of local corticosteroid injection by USG and palpation guidance in plantar fasciitis. Methods: This was a prospective randomized study of patients who presented with heel pain between July 2015 and November 2016 and were screened for plantar fasciitis by USG. Patients with confirmed plantar fasciitis were managed conservatively for 4 weeks. The 60 consecutive patients not responding to the conservative treatment were randomized into two groups. Group A (n = 30) received a corticosteroid injection under USG guidance. Group B (n = 30) received a corticosteroid injection under palpation guidance. Patients were followed up at 3 and 6 weeks. We compared the visual analog scale score, plantar fascia thickness, and heel pad thickness in both groups. Results: There was significant pain relief in both groups after 3 and 6 weeks of local corticosteroid injection, with greater relief noted in the USG-guided group. There was a significant decrement in plantar fascia thickness in both groups after 3 and 6 weeks; however, a greater decrement was observed in the USG-guided group. Neither group showed a significant difference in heel pad thickness after 3 and 6 weeks. Conclusions: Ultrasound-guided injection provided better pain relief and a greater reduction in plantar fascia thickness than palpation-guided injection.

INTRA-ARTICULAR KNEE INJECTION TECHNICAL SUCCESS RATE—COMPARISON BETWEEN ULTRASOUND- AND PALPATION-GUIDED INJECTION USING RADIOGRAPHIC DEPICTION OF INTRA-ARTICULAR AIR AS REFERENCE STANDARD

To date no study has investigated the actual technical success rate of IA injections into the joint space. Knowledge of technical success is relevant to determine potential efficacy confounders due to inappropriate injection. The aim of this study was to determine the success rate of intra-articular injection of an investigational treatment of knee osteoarthritis pain into the knee joint with and without ultrasound guidance, using radiographic documentation of intra-articular air injection as the reference. Between December 2020 and March 2022, 216 patients underwent intra-articular injection of an investigational treatment, a cryopreserved Amniotic Suspension Allograft (ASA, Organogenesis, Canton, MA) into the knee joint, either under ultrasound guidance or with palpation-based injection without imaging guidance. Injection of the study treatment was performed in a phase 3 prospective double-blind, multicenter, placebo-controlled, parallel group, randomized control trial (RCT) in subjects with moderate to severe symptomatic knee osteoarthritis. Injection was performed by physicians or physician-assistants in Orthopedics, Internal Medicine, Rheumatology, or Radiology. Inclusion criteria were the presence of radiographic knee OA (Kellgren and Lawrence grade 2 or above) and knee pain. About half of the recruited patients underwent ultrasound guided injection and the other half had palpation-guided injection without imaging guidance. 1 mL of 1% lidocaine was used to anesthetize the skin and periarticular tissues with a 27g needle prior to using a 21g 1.5-inch needle or 22g 3-inch needle for joint aspiration and injection of either ASA (2mL ASA + 2 mL saline) or 4 mL placebo (USP normal saline). After the injection of study treatment, and with the needle in the same exact location, 10 mL of air were injected, and a lateral X-ray of the knee was performed within 10 minutes to document the presence of intra-articular air. Radiographs were read by a musculoskeletal radiologist blinded to injection technique. Patients’ age, gender, body mass index (BMI), and radiographic knee OA grade were recorded. Collected data (success rate of intra-articular injection) were stratified according to guidance method (with or without ultrasound), approach of injection (medial, lateral suprapatellar, anterior), specialty of injector (Orthopedics, Rheumatology, Internal Medicine, or Radiology), experience of injector (<10 years, 10 years or more but <20 years, 20 years or more), sex, BMI, and Kellgren and Lawrence grade. One-sided Cochran-Armitage test for trend was used to evaluate if there was decreasing success rate with increasing BMI, and to evaluate if there was increasing success rate with increasing injector experience. Included were 216 patients whose mean age was 59.8 (SD ± 10.2) years, and mean BMI 30.6 (4.8). 134 patients were male (62.0%). 94 patients had US-guided injection and 117 patients had palpation-guided injection. Details of demographic characteristics are summarized in Table 1. Of these, 159 injections were intra-articular and 42 extra-articular. 3 injections were indeterminate since air was not visible on the X-ray and excluded from analysis. Although US-guided injection had higher success rate (80/94, 85.1%) than palpation-based injection (89/117, 76.1%), there was no statistically significant difference (p=0.10). There was no difference of success rate with respect of injection approach (medial or lateral, p=0.75). No statistically significant difference in success rate was seen regarding injector specialty, patient sex, BMI, or radiographic OA grade (Table 1). Table 2 also shows more experienced injectors had better success rate than less experienced injectors albeit not statistically significant (p=0.11). There was no trend for decreasing success rate of intra-articular injection with increasing BMI (3 categories), with p-value=0.43. Neither ultrasound-guided nor palpation-guided injection provides 100% success rate for intra-articular injection of the knee as demonstrated by intra-articular air visualization on radiography. The more experienced operators have a higher success rate, with a threshold of 10 years of experience, while specialty or training seems to be less relevant. While ultrasound-guided injection showed somewhat higher success rates compared to palpation-guided injection, documentation of intraarticular injection using air seems paramount to avoid subsequent extra-articular injection of investigational or disease modifying osteoarthritis drug (DMAOD) compound and thus, maximize efficacy. No funding was received for the analysis of this Study. AG has received consultancies from Pfizer, Novartis, Regeneron, AstraZeneca, Merck Serono, and TissueGene and is shareholder of Boston Imaging Core Lab (BICL), LLC. FWR is shareholder of BICL, LLC. and has received consultancies, speaking fees, and/or honoraria from Calibr –California Institute of Biomedical Research and Grünenthal, GmbH. MDC is shareholder of BICL, LLC. CORRESPONDENCE ADDRESS: [email protected]

Radio-carpal wrist MR arthrography: comparison of ultrasound with fluoroscopy and palpation-guided injections.

To compare ultrasound- (US), fluoroscopy- (FL), and palpation-guided contrast injection techniques used for dorsal radio-carpal wrist MRA. Patients with chronic wrist pain were randomized as to which injection technique they underwent into three groups of 50 participants. Dorsal radio-carpal contrast injection was performed under US, FL guidance (one radiologist for each), or palpation guidance by an orthopedic surgeon. The three techniques were compared by procedure time, success rate, number of attempts needed, frequency and grade of extravasation, joint distension, and MRA image quality. Additionally, any change from baseline wrist pain was recorded using the visual analog scale (VAS) at five time points (immediately, 8h, 24h, 48h, and 1week) after injection. One hundred and fifty patients (83 males and 67 females; mean age 29 ± 6.5years) were included. Success rates for US- and FL-guided injections were 100%, while palpation-guided approach was significantly less successful (72%) (P = 0.02) with significantly more frequent extravasation (56%)(P < 0.001). US guidance was the least time-consuming (6.5 ± 1.6min) compared to FL guidance (12.5 ± 1.9min) and palpation guidance (8 ± 1.2min) (all P < 0.001). The mean number of joint puncture attempts was significantly lower with imaging-guided techniques (1.1 ± 0.24 and 1.2 ± 0.4 for US and FL, P = 0.23) compared to palpation-guided one (1.6 ± 0.8) (P = 0.007). The largest increases in baseline-pain were 8-h post-injection, and US guidance was the least painful at all-time points (all P < 0.05). Joint distension and image quality were significantly better with imaging-guided techniques (P < 0.001 and P = 0.003). US-guided radio-carpal injection is a less time-consuming, more tolerable, and successful radiation-free method when compared to FL guidance. Palpation-guided injections require multiple attempts to enter the joint with high failure rates and frequent extravasation.

Techniques for Injection of the Scaphotrapezium-Trapezoid Joint Without Image Guidance

PurposeScaphotrapezium-trapezoid (STT) joint arthritis is one of the most common forms of wrist arthritis. Conservative management often involves corticosteroid injection. Despite this, there is a scarcity of literature on palpation-guided injection techniques for the STT joint. We aimed to determine a standardized palpation-guided injection method that is easily reproducible and poses minimal risk to local anatomic structures.MethodsSix fresh-frozen cadaveric upper extremity specimens were tested. Access to the STT joint was attempted with dorsal, volar, and radial approaches. Fluoroscopy was used to confirm accurate placement within the joint. Needle placement was documented in relation to the surrounding soft tissue and bony landmarks were measured with a ruler, and the angle of the needle entry was recorded using a goniometer. The cadavers were carefully dissected to identify the surrounding neurovascular structures at risk of injury.ResultsTo access the STT joint with the dorsal approach, the needle was angled at 90º and inserted one-third of the distance from the prominence of the base of the second metacarpal to Lister tubercle. No neurovascular structures were found in the immediate vicinity of the needle. For the volar approach, the needle was angled at 65º and inserted at the distal wrist crease, 1 cm ulnar to the radial border of the wrist, in line with the second metacarpal. The volar branch of the radial artery was at risk with this approach. For the radial approach, the needle was angled at 60º and inserted immediately dorsal to the extensor pollicis brevis tendon, midway between the radial styloid and the prominence of the thumb metacarpal base. The dorsal branch of the radial artery was at risk with this approach.ConclusionsIn a clinical setting where fluoroscopy or ultrasound is not readily available, the dorsal approach may allow for safe and accurate placement of the injectate into the STT joint.Type of study/level of evidenceTherapeutic IV.

Injection Placement for Palpation-Guided Intra-Articular Glucocorticoid Therapy for the Elbow

Objectives: There are two different palpationguided injection techniques described how to enter the elbow joint when injecting intraarticular glucocorticoids – the lateral and the posterior. Both methods are used in clinical practice and based on individual experience each practicing physician decides which technique to use. The aims of the present study were to compare the accuracy of palpationguided injection placement and the clinical effects regarding pain and function between these methods.

Ultrasound imaging and guidance in peripheral nerve entrapment: hydrodissection highlighted.

Ultrasound (US) imaging has become one of the most useful modalities to assess peripheral nerve disorders. Nowadays, it is as important as nerve conduction studies and electromyography for peripheral nerve entrapment. Additionally, US is also helpful in guiding a possible intervention. As peripheral nerves are tiny, palpation-guided injections are really challenging for precisely targeting the nerves. By using US, perineural injections have significantly become safe and effective. Recently, US-guided hydrodissection has emerged as the mainstream for nerve entrapment. Accordingly, this review aims to summarize and update the mechanism and evidence regarding this imperative procedure for neuropathic pain management. Furthermore, the pathogenesis, anatomic features, US findings and histological correlations of nerve entrapment syndromes will also be discussed in this article.

Top-Ten Tips for Ultrasound-Guided Joint Injection.

Ultrasound-guided joint injection is more accurate than palpation-guided injection and performed more frequently. Joint injection is helpful for therapeutic and diagnostic purposes as well as for injecting contrast agents for magnetic resonance imaging or computed tomography arthrography. Ultrasound-guided joint injection helps ensure intra-articular injection and minimizes injury to para-articular soft tissues.

Image-guided versus palpation-guided injections for the treatment of chronic lateral epicondylopathy: a randomized controlled clinical trial.

There have been several studies published comparing the ultrasound-guided with the "blind" infiltrations in the shoulder's area. On the contrary, there is only very limited data regarding the necessity of ultrasound guidance in lateral epicondylitis. A prospective, randomized, blinded at initial and follow-up evaluation, comparative clinical trial was conducted, involving 44 patients with a history of chronic persistent epicondylopathy. The patients were randomly divided into 2 groups of 22 people each. Group A patients underwent three ultrasound-guided betamethazone injections, while group B included those who underwent three "blind" injections, centered at the palpable point of maximum pain. The evaluation was done before and after (4 and 12 weeks) the injections using the Visual Analogue Scale for pain (VAS, 0-10) and the Roles & Maudsley score. There was not any significant statistical difference between the two groups as for mean VAS at 4 weeks (p = 0.150, t-test) and mean VAS at 12 weeks (p = 0.286, t-test). Furthermore, the final success rate, as measured by the Roles & Maudsley score, was slightly superior in group B (67 % of the patients with excellent or good results) when compared with group A (46 % of the patients), but without any statistical difference (p = 0.161, chi-square). Our trial proved that an ultrasound-guided injection is not superior than a palpation-guided injection of corticosteroids in the treatment of lateral epicondylopathy.

Ultrasound-Guided Intervention for Treatment of Trigeminal Neuralgia: An Updated Review of Anatomy and Techniques.

Orofacial myofascial pain is prevalent and most often results from entrapment of branches of the trigeminal nerves. It is challenging to inject branches of the trigeminal nerve, a large portion of which are shielded by the facial bones. Bony landmarks of the cranium serve as important guides for palpation-guided injections and can be delineated using ultrasound. Ultrasound also provides real-time images of the adjacent muscles and accompanying arteries and can be used to guide the needle to the target region. Most importantly, ultrasound guidance significantly reduces the risk of collateral injury to vital neurovascular structures. In this review, we aimed to summarize the regional anatomy and ultrasound-guided injection techniques for the trigeminal nerve and its branches, including the supraorbital, infraorbital, mental, auriculotemporal, maxillary, and mandibular nerves.

Botulinum toxin type A with or without needle electromyographic guidance in patients with cervical dystonia.

AimTo investigate the efficacy and safety of electromyography (EMG)- and palpation-guided botulinum toxin type A injection in cervical dystonia (CD) patients.MethodsIn this randomized, controlled trial, 68 CD patients were randomly allocated to two groups, receiving botulinum toxin type A injections guided by either palpation (Group A) or EMG (Group B). The primary endpoint is defined as the difference in the Tsui score between groups at 16 weeks. The secondary endpoints were the visual analog scale (VAS) and Hospital Anxiety and Depression Scale (HADS) scores and Clinical and Patient Global Impression of Change (CGIC and PGIC).ResultsSixty-five patients completed the study. No significant difference was observed in the Tsui score between groups A and B at 4, 8, and 12 weeks after treatment (p > 0.05). However, 16 weeks after treatment, the Tsui score of group A was significantly higher than that of group B. For both groups, the degree of pain at each time point during follow-up significantly reduced after treatment. However, no significant difference was observed in VAS scores between the two groups. Interestingly, the patient HADS score decreased without statistical significance 8 weeks following treatment. No significant difference in HADS scores was observed between the two groups. Additionally, there was no significant difference in PGIC and CGIC between the two groups. However, CGIC was significantly higher than PGIC. No significant difference in adverse reactions was observed between groups. CD patients treated with EMG guidance experienced a significantly more pain at the injection site but a significantly lower adverse event occurrence rate of dysphagia when compared to CD patients treated with palpation guidance only.ConclusionsCD patients treated with EMG guidance experienced a prolonged benefit as measured by the Tsui scale when compared to CD patients treated with palpation guidance alone. EMG-guided injection resulted in a lower incidence of dysphagia and higher incidence of discomfort at the injection site than palpation-guided injection.

Efficacy of Ultrasound-Guided Corticosteroid Injections

There have been many recently published articles reporting improved accuracy of corticosteroid injection with the use of ultrasound-guidance compared to the conventional method of palpation-guided injections. It has been postulated that this improved accuracy would result in improved clinical outcomes. However, studies have been mixed in regards to whether ultrasound-guidance improves efficacy of corticosteroid injections. There is a significant need for high-quality research to be performed to adequately answer this question. This review summarizes the currently published studies comparing the efficacy of ultrasound- and palpation-guided corticosteroid injections.

2090419 Localizing Maximal Distention in the Subdeltoid Bursa by Point-Of-Care Ultrasound Alters The Ultrasound-Guided Injection Approach

Palpation-guided corticosteroid (CS) injections are often provided from a posterior approach, aiming at the subacromial aspect of the subdeltoid bursa with varying accuracy and treatment response. Ultrasound (US) can visualize bursal fluid, thickening, tendinopathy, and tendon tears. US-guided injections are known to be accurate. Our OBJECTIVES: was to evaluate how point-of-care US affects the US-guided injection approach for treatment of shoulder pain. We retrospectively reviewed clinical and US characteristics of 67 patients with shoulder pain/impingement syndrome who received a total of 96 US-guided CS injections in an academic rheumatology US clinic. Images were obtained and interpreted by 1 expert MUS-trained rheumatologist. All images were reviewed by a 2nd US-trained physiatrist. Patients were mostly female (64.2%) with a mean age of 63.5 and BMI of 29.1. Twenty-six patients (38.8%) received prior palpation-guided injections with more than half of these patients (61.5%) reporting little to no benefit. US-guided injection approach was determined by localizing the maximal area of fluid distention or thickening of the subdeltoid bursa visualized by US, corresponding with clinical tenderness. US-guided injections were provided in the typical subacromial target, laterally over the supraspinatus tendon in 41.7% of injections; however, 58.3% of injections were targeted anterior to the acromion: anterolaterally over the subscapularis tendon (35.4%), anterolaterally over the supraspinatus tendon (20.8%) and anteriorly over the biceps tendon (2.1%). The majority of all US-guided injections (96.8%) provided improvement to complete relief immediately post-injection. Point-of-care US identified maximal distention of the subdeltoid bursa to be more commonly located anterior to the acromion rather than directly subacromial. This finding may be a reason for failed palpation-guided injections. US-guided injection approach was altered by targeting a specific location with clinical correlation. This method has the potential to improve clinical outcomes. Future prospective studies are needed.

Ultrasound- versus Palpation-Guided Injection of Corticosteroid for Plantar Fasciitis: A Meta-Analysis

BackgroundIt is controversial whether ultrasound-guided injection of corticosteroid is superior to palpation-guided injection for plantar fasciitis. This meta-analysis was performed to compare the effectiveness of ultrasound-guided and palpation-guided injection of corticosteroid for the treatment of plantar fasciitis.MethodsDatabases (MEDLINE, Cochrane library and EMBASE) and reference lists were searched from their establishment to August 30, 2013 for randomized controlled trials (RCTs) comparing ultrasound-guided with palpation-guided injection for plantar fasciitis. The Cochrane risk of bias (ROB) tool was used to assess the methodological quality. Outcome measurements were visual analogue scale (VAS), tenderness threshold (TT), heel tenderness index (HTI), response rate, plantar fascia thickness (PFT), hypoechogenicity and heel pad thickness (HPT). The statistical analysis was performed with software RevMan 5.2 and Stata 12.0. When I2<50%, the fixed-effects model was adopted. Otherwise the randomized-effects model was adopted. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the quality of evidence.ResultsFive RCTs with 149 patients were identified and analyzed. Compared with palpation-guided injection, ultrasound-guided injection was superior with regard to VAS, TT, response rate, PFT and hypoechogenicity. However, there was no statistical significance between the two groups for HPT and HTI.ConclusionUltrasound-guided injection of corticosteroid tends to be more effective than palpation-guided injection. However, it needs to be confirmed by further research.

Is Ultrasound-Guided Injection More Effective in Chronic Subacromial Bursitis?

Although ultrasound (US)-guided subacromial injection has shown increased accuracy in needle placement, whether US-guided injection produces better clinical outcome is still controversial. Therefore, this study aimed to compare the efficacy of subacromial corticosteroid injection under US guidance with palpation-guided subacromial injection in patients with chronic subacromial bursitis. Patients with chronic subacromial bursitis were randomized to a US-guided injection group and a palpation-guided injection group. The subjects in each group were injected with a mixture of 0.5 mL dexamethasone suspension and 3 mL lidocaine into the subacromial bursa. The primary outcome measures were the visual analog scale for pain and active and passive ranges of motion of the affected shoulder. Secondary outcome measures were the Shoulder Pain and Disability Index, the Shoulder Disability Questionnaire, and the 36-item Short-Form Health Survey (SF-36). The primary outcome measures were evaluated before, immediately, 1 wk, and 1 month after the injection; the secondary outcome measures were evaluated before, 1 wk, and 1 month after the injection. Of the 145 subjects screened, 46 in each group completed the study. Significantly greater improvement in passive shoulder abduction and in physical functioning and vitality scores on the SF-36 were observed in the US-guided group. The pre- and postinjection within-group comparison revealed significant improvement in the visual analog scale for pain and range of motion, as well as in the Shoulder Pain and Disability Index, Shoulder Disability Questionnaire, and SF-36 scores, in both groups. The US-guided subacromial injection technique produced significantly greater improvements in passive shoulder abduction and in some items of the SF-36. US is effective in guiding the needle into the subacromial bursa in patients with chronic subacromial bursitis.

Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance

This randomized controlled study addressed whether sonographic needle guidance affected the outcomes of corticosteroid injection for symptomatic carpal tunnel syndrome. Seventy-seven symptomatic carpal tunnels were randomized to injection by either (1) conventional anatomic landmark palpation-guided injection or (2) sonographic image-guided injection, each using a two-step technique where 3 ml of 1% lidocaine was first injected to hydrodissect and hydrodisplace critical intra-carpal tunnel structures followed by injection with 80 mg of triamcinolone acetonide (2 ml). Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, total cost, and cost per responder were determined. There were no complications in either treatment group. Relative to conventional anatomic landmark palpation-guided methods, sonographic guidance for injection of the carpal tunnel resulted in 77.1% reduction in injection pain (p<0.01), a 63.3% reduction in pain scores at outcome (p<0.014), 93.5% increase in the responder rate (p<0.001), 84.6% reduction in the non-responder rate (p<0.001), a 71.0% increase in therapeutic duration (p<0.001), and a 59.3% ($150) reduction in cost/responder/year for a hospital outpatient (p<0.001). However, despite improved outcomes, cost per patient per year was significantly increased for an outpatient in a physician's office and was neutral for a hospital outpatient. Sonographic needle guidance significantly improves the performance and clinical outcomes of injection of the carpal tunnel and is cost-effective for a hospital-based practice, but based on current reimbursements, it significantly increases overall costs for medical care delivered in a non-hospital-based physician practice.

Impact of outpatient clinic ultrasound imaging in the diagnosis and treatment for shoulder impingement: a randomized prospective study

The use of musculoskeletal ultrasonography (MSUS) in guiding subdeltoid injection has been shown to improve outcome up to 6 weeks in a few small studies. A recent meta-analysis identified the need for further studies with longer-term outcome and larger sample size. This randomized prospective study assessed whether clinic-based MSUS can significantly improve diagnostic accuracy in shoulder pain and whether MSUS-guided shoulder injection results in improved long-term outcomes. One hundred consecutive patients with 125 painful shoulders were recruited. Patients were randomized to receive either sonographic assessment with consequent palpation-guided injection (Group 1, n = 66) or sonographic assessment with a MSUS-guided injection of 40 mg of methylprednisolone acetate (Group 2, n = 59). A blinded rheumatologist (ADF) performed clinical assessments at baseline, 6 and 12 weeks including shoulder function tests (SFTs) (Hawkins-Kennedy test, supraspinatus tendon tenderness), physician global assessment (PGA) and patient visual analogue scores (VAS) for pain (0-10). Eighty patients with 90 symptomatic shoulders completed 12-week follow-up. Twenty patients, 11 (20 shoulders) from the palpation-guided group and 9 (15 shoulders) from the MSUS-guided group, were excluded at 6 weeks either due to requirement for repeat injection or due to surgical referral. Mean age for patients was 57.7 years, and 65 % patients were female; mean shoulder pain duration was 18 weeks (range 14-22 weeks). SFTs, patient VAS and PGA scores for pain improved significantly from baseline in both groups with significantly greater improvements in the MSUS-guided group (44 shoulders) compared to the palpation-guided group (46 shoulders) in all parameters at 6 (p < 0.01) and 12 weeks (p < 0.05). The use of MSUS in guiding subdeltoid injection has been shown to improve outcome up to 6 weeks in a few small studies. A recent meta-analysis identified the need for further studies with longer-term outcome and larger sample size.

Palpation versus ultrasound-guided corticosteroid injections and short-term effect in the distal radioulnar joint disorder: a randomized, prospective single-blinded study

The aim of this study was to conduct a randomized, prospective single-blinded clinical study on the mid-term benefits and accuracy rate of the ultrasound (US)-guided versus palpation-guided intra-articular (IA) injections for the treatment of distal radioulnar joint (DRUJ) disorder. Subjects with DRUJ disorder (n = 60) were randomly assigned to undergo US-guided or palpation-guided IA injection. Primary outcomes were measured with Disability of the Arm, Shoulder, and Hand questionnaire (DASH) and secondary outcomes included Verbal Numeric Pain Scale (VNS), Modified Mayo Wrist Score (MMWS), range of motion (ROM), and accuracy rate between two groups; 1.25 mL of mixed material (0.5 ml Omnipaque + 1 % lidocaine 0.25 ml + triamcinolone 20 mg 0.5 ml) was injected into the intra-articular space of the DRUJ. Treatment effects were assessed by using VNS, DASH, MMWS, and passive ROM of the DRUJ (supination, pronation from neutral) before the injections and at 1, 3, and 6 months after the injections. After the US-guided and palpation-guided IA injection into DRUJ, a radiographic image was taken to determine whether the injected material had reached the IA space or infiltrated into the soft tissue. US-guided IA injections showed significantly higher accuracy (100 %) than palpation-guided IA injections (75.8 %) in DRUJ. VNS, DASH, MMWS, and ROM were improved at 1, 3, and 6 months in both groups. There was no significant difference in clinical outcomes between the group receiving US-guided injections and the group receiving palpation-guided injections. US-guided IA injection showed significantly higher accuracy than palpation-guided IA injection in the DRUJ, and corticosteroid IA injections were effective in improving of the pain of patients with DRUJ disorder during 6 months of follow-up.

Effectiveness of Device-Assisted Ultrasound-Guided Steroid Injection for Treating Plantar Fasciitis

The aim of this study was to investigate the effectiveness of device-assisted ultrasound-guided steroid injection for treating plantar fasciitis. An ultrasound-guided injection device designed with space for securing a transducer and syringe was used to guide steroid injection. Patients with unilateral plantar fasciitis were enrolled and randomly divided into device-assisted ultrasound-guided and palpation-guided groups. Pain intensity was measured using a visual analog scale and tenderness threshold. Ultrasound and pain intensity evaluations were performed before injection and at 3 wks and at 3 mos postinjection. Betamethasone (7 mg) and 1% lidocaine (0.5 ml) were injected into the inflamed plantar fascia. Thirty-three patients who received either device-assisted ultrasound-guided or palpation-guided injection had significantly lower visual analog scale scores (P < 0.001) and higher tenderness threshold (P < 0.01) postinjection. However, the device-assisted group had higher tenderness threshold (9.02 ± 1.38 vs. 7.18 ± 2.11 kg/cm; P = 0.007), lower visual analog scale score (1.88 ± 2.13 vs. 3.63 ± 2.60; P = 0.046), and lower hypoechogenicity incidence in the plantar fascia (3/16 vs. 9/16; P = 0.033) than the palpation-guided group did at 3 mos postinjection. The heel pad was significantly thin (P = 0.004) in the palpation-guided group postinjection. Device-assisted ultrasound-guided injection for treating plantar fasciitis results in better therapeutic outcomes than palpation-guided injection does.