Subacromial Bursitis Research Articles

Streptobacillus moniliformis bacteraemia and septic arthritis in a child

Streptobacillus species are zoonotic pathogens colonising the oral cavity and upper respiratory tract of rats and other rodents.1 Transmission occurs via bites or scratches, referred to as rat-bite fever, or ingestion of contaminated food or water, referred to as Haverhill fever.1,2 Streptobacillus species are rarely isolated due to fastidious growth requirements, inhibition by sodium polyanethol sulfonate anticoagulant in blood culture bottles, and susceptibility to commonly-used antibiotics.1 A 12-year-old immunocompetent female with pet mice and rats presented with fever, left shoulder pain, and rash for five days. Examination demonstrated left axillary lymphadenopathy and left glenohumeral joint restricted range of motion, swelling, and warmth. Ultrasound confirmed a moderate glenohumeral joint effusion and subacromial bursitis. Arthroscopic washout of the joint revealed diffuse, non-purulent, synovitis. The synovial fluid cell count was 15,300×106/L with a mononuclear cell predominance. Streptobacillus moniliformis was isolated in culture of blood (paediatric blood culture bottle) and synovial fluid specimens after approximately 72 hours at the microbiology laboratory at Nepean Hospital. The patient admitted to kissing her pet rodents on their mouths and sustaining scratches to the skin of her hands whilst bathing them. She recovered completely with intravenous ceftriaxone for one week then oral amoxycillin for three weeks.

Correlation between the Findings of Magnetic Resonance Imaging Shoulder and Shoulder Arthroscopy

Introduction: Shoulder pain is a significant cause of decreased functional activity of an individual. The overall prevalence of shoulder pain is 16-26%, which makes it the third most common cause among musculoskeletal complaints. The cause of pain in the shoulder is often difficult to evaluate, and diagnosis is usually ambiguous because physical findings are poorly reproducible. The diagnosis therefore, requires multiple imaging modalities. Therapeutic arthroscopy is “the current gold standard” for diagnosing shoulder pathologies, however the procedure is invasive, needs hospitalisation and anaesthesia. Aim: To correlate the findings of Magnetic Resonance Imaging (MRI) shoulder with the findings of shoulder arthroscopy and subsequently determine sensitivity, specificity and accuracy of MRI in diagnosing shoulder pathologies. Materials and Methods: Forty two patients suffering from chronic shoulder pain for a period of more than six weeks, having symptoms of instability, clinical signs of tear or impingement, or functional limitation of the affected shoulder were included in this study. The patients included were in the age group of 18-80 years. Subsequently, MRI followed by arthroscopy of the shoulder was done and the findings of MRI were compared to that of arthroscopy using kappa statistics. Results: In this study along with rotator cuff tear (26 patients), subacromial bursitis (26 patients), was the other most common shoulder pathology. The sensitivity of MRI in detecting shoulder pathologies varied from poor (0.28) for Superior Labrum Anterior Posterior (SLAP) lesion to very good (0.88) for Bankart’s tear and (0.8) for synovial chondromatosis to excellent for rotator cuff tears (0.92). Although sensitivity of MRI was variable for different shoulder pathologies, specificity was comparatively high in detecting all of the above shoulder pathologies. The accuracy of MRI was highest (0.95) in diagnosing synovial chondromatosis, followed by bankart’s lesion (0.92), and rotator cuff tear (0.88). Conclusion: MRI is a very useful and effective tool in diagnosing various shoulder pathologies with exception of SLAP tears where its sensitivity diminishes significantly.

Acupuncture for symptomatic rotator cuff disease: Protocol for a systematic review and meta-analysis.

Rotator cuff disease (RCD) consists of subacromial impingement syndrome, rotator cuff tendinopathy or tendinitis, partial or full rotator cuff tear, calcific tendinitis, and subacromial bursitis. Acupuncture has been suggested as a meaningful nonsurgical intervention for managing shoulder pain and dysfunction. However, previous reviews have not completely addressed the role of acupuncture in the management of RCDs. The objective of this systematic review is to evaluate the effectiveness and safety of acupuncture for managing symptoms in patients with RCD. We will search the following databases from their inception to November 30, 2019: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED), Physiotherapy Evidence Database (PEDro), 3 Chinese databases (China Academic Journal Full-text Database (CAJ), China Doctoral Dissertations Full-text database and China Masters' Thesis Full-text Database), 6 Korean databases (Korean studies Information Service System (KISS), National Digital Science Library (NDSL), Research Information Sharing Service (RISS), Korean Medical Database (KMBASE), Korea Institute of Science and Technology Information (KISTI), Oriental Medicine Advanced Searching Integrated System (OASIS)), and 3 trial registries (ClinicalTrials.gov, International Standard Randomized Controlled Trials Number (ISRCTN) Registry, WHO International Clinical Trials Registry Platform (ICTRP)). We will include randomized controlled trials of acupuncture for RCD. There will be no restrictions related to setting or location. The primary outcome is pain intensity and shoulder dysfunction measured on validated scales within 12 weeks. Quality assessment will be performed using the Cochrane risk of bias tool. Dichotomous outcomes will be presented as risk ratios (RR), and continuous outcomes will be presented as weighted or standardized mean differences (SMD). Each outcome will be calculated with 95% confidence intervals. The updated evidence that would be provided by this review will offer useful information for patients and practitioners, and also have implications for future studies and the development of clinical practice guidelines of RCD.Registration: Open Science Framework (OSF) Preregistration. 2019, December 5. osf.io/n2e6t.

Il trattamento delle lesioni massive di cuffia con lo spaziatore biodegradabile sottoacromiale

The treatment of massive rotator cuff tears remains a challenge for orthopaedic surgeons. There are several arthroscopic possibilities in the absence of glenohumeral arthrosis: debridement with or without tenotomy of the long head of the biceps, partial cuff repair, use of synthetic patches and insertion of a biodegradable spacer. The aim of our study was to provide a clinical and subjective analysis of patients treated in our centre using the InSpace™ balloon. The spacer is positioned in the subacromial space. This device should reduce subacromial friction so as to lead to pain reduction and improvement in the range of motion. We analysed 27 patients (15 men and 12 women) treated with this technique between December 2014 and December 2018 in our Operative Unit. Mean age was 65 years (49–71) and average follow-up time was 24.4 months. All patients had massive rotator cuff lesions associated with subacromial bursitis. In 16 cases this lesion was associated with biceps tendinitis and, in 4 patients, with partial lesion of the subscapularis tendon. Patients underwent bursectomy and tenotomy of the long head of the biceps brachii. In 6 cases the cuff was partially reconstructed using 1 or 2 anchors and side-to-side sutures. The average Constant Score rose from 11.33/100 to 78.00. In 4 cases the Constant Score was unsatisfactory, while in the remaining patients it exceeded 85 points. The UCLA score increased from an average value of 1.33/10 points to 8.62, while the SST score rose from 2.33/12 to 10.54 points. The final result seems to be independent of severity of the initial injury, time elapsed and cuff reconstruction. Proper use of the spacer seems to be effective against pain and ROM restoration. Our goal is to continue the follow-up in these patients and to evaluate the advantages of this device in a larger sample.

Effect of Combined Ultrasound-guided Subdeltoid Corticosteroid Injections and Physiotherapy in Treatment of Patients With Chronic Subacromial Bursitis

Effect of Combined Ultrasound-guided Subdeltoid Corticosteroid Injections and Physiotherapy in Treatment of Patients With Chronic Subacromial Bursitis

Hot topics in musculoskeletal ultrasound

The topics chosen for discussion in this presentation include commonly encountered conditions and scenarios that seem to cause difficulties and confusion for sonographers and radiologists. A good place to start is the vexed issue of subacromial bursitis and impingement. ‘Subacromial bursitis’ is often reported on ultrasound due to apparent thickening of the bursa. This thickening may be accentuated in abduction (‘bursal bunching’) and accompanied by pain leading to the reporting of ‘impingement’. The lack of clear evidence as to what constitutes a thickened bursa, and the meaning of the term ‘impingement’ will be explored. Another common scenario is ultrasound of the adult hip for ‘trochanteric bursitis’. Multiple bursa compartments are present between and adjacent to the tendons and muscles near the greater trochanter, and thin slips of fluid in these spaces are common. Pathologically proven trochanteric bursitis is uncommon, and usually associated with pathology of the gluteal tendons. Pain at the greater trochanter is very common, especially in elderly people. ‘Trochanteric bursitis’ is best thought of as a regional pain syndrome with various causes. The dominant role for ultrasound in this context is guidance of injection of steroid and local anaesthetic. Ultrasound of soft tissue masses is common, and usually straightforward in well characterised lesions like ganglia and lipomas. Sometimes however, ultrasound is unable to provide a specific diagnosis. This should not be the end of things. Based on their ultrasound features, unknown lesions should be sorted into either ‘probably benign’ or ‘indeterminate/ possibly malignant’, and further follow up recommended, such as MRI or specialist assessment. Rotator cuff repair is an increasingly common procedure. It may be performed with an open or arthroscopic technique, which consists of reattachment of the torn tendon to the humeral head with suture anchors. Patients may present with residual or recurrent pain or dysfunction for which imaging is required. A repaired cuff tendon will probably never look completely normal on ultrasound. Heterogeneity, thinning, and small residual defects are common post repair, as are bursal fluid and bone surface irregularity. In general terms, if fibres can be followed to the suture anchors, then the repair is probably intact. Correlation of surgical technique and direct consultation with the surgeon may be required in difficult cases.

The effectiveness of eccentric loading exercises in the management of rotator cuff tendinopathy: a structured literature review

Purpose: Shoulder pain is one of the most common reasons patients attend outpatient physiotherapy clinics after low back pain. Waiting lists to see an Orthopaedic surgeon regarding shoulder pain is on the rise, particularly in Northern Ireland. Rotator cuff tendinopathy and sub-acromial bursitis have been used interchangeably as a diagnosis under the umbrella term shoulder impingement syndrome and after numerous treatment options have failed, patients are referred for surgical opinion. Tendinopathy has been successfully treated in lower limb for Achilles and patellar tendinopathy using eccentric exercises, and only more recently in the last 10 years regarding the rotator cuff.

Risk factors for rotator cuff tendinopathy: A systematic review and meta-analysis.

To conduct a systematic review and meta-analysis to identify risk and associated factors for symptomatic rotator cuff tendinopathy. PubMed, CINAHL and Scopus were searched from inception to June 2017. Participants presented with signs and symptoms suggestive of rotator cuff tendinopathy/tendinosis/tendinitis, shoulder impingement syndrome, or subacromial bursitis diagnosed by clinical tests and/or conventional imaging. Screening, quality assessment and data extraction were carried out by 2 reviewers. Sixteen studies were included in this review. Overall, 22 factors were identified and 5 factors were explored using meta-analysis. Pooled analyses provided strong evidence that age above 50 years (odds ratio (OR)?=?3.31, 95% confidence interval (95% CI)?=?2.304.76, I2?=?0%, p<0.001) and diabetes (OR?=?2.24, 95% CI?=?1.373.65, I2?=?0%, p?=?0.001) were associated with increased risk of rotator cuff tendinopathy. In addition, moderate evidence showed that work with the shoulder above 90° was associated with increased risk of rotator cuff tendinopathy (OR?=?2.41, 95% CI?=?1.314.45, I2=?83%, p?=?0.005). Age above 50 years, diabetes and overhead activities were associated with increased risk of rotator cuff tendinopathy.

Outcomes Following Ultrasound Versus Blinded Subacromial Injection - a Randomized Clinical Trial

The purpose of this study was to evaluate the clinical outcomes of ultrasound-guided versus blind subacromial injections in patients who have clinical and radiographic sign of subacromial bursitis. Specifically, we evaluated: (1) function; (2) pain; and (3) activity level.

An initial experience with the use of whole body MRI for cancer screening and regular health checks.

ObjectivesWe evaluated the utility of whole-body MRI (WB MRI) for cancer screening and other regular health evaluations.MethodsThis retrospective study included 229 patients who underwent whole-body MRI as part of a routine health examination and cancer screening. The WB MRIs and radiologic reports were evaluated by a musculoskeletal radiologist, a neuroradiologist, and an abdominal radiologist. The consensus of their findings was characterized into three categories, as follows: suspicion of malignancy (category I); need for follow-up (category II); and no need for follow-up (category III). Any correlations between the abnormal findings and each study group were evaluated using the Mann-Whitney U test and chi-square test.ResultsThere were six category I lesions, among which two cases were found to involve malignancy. The most common category II findings were annular tears of the disc (14% of category II findings) and severe disc bulging or protrusion, followed by shoulder bursitis and uterine myoma. The most common category III finding was mild disc bulging or protrusion (47% of category III findings).ConclusionsWB MRI can be used in cancer screening and for regular health evaluations. WB MRI not only provides information about potential malignancy, but also provides information regarding nonmalignant abnormalities that require further evaluation.

The diagnosis and management of shoulder pain.

Diagnosis is crucial in decision-making when treating a patient with shoulder pain. Ultrasound is also very important in the diagnostic and therapeutic pathway, especially when surgery is being considered. This article outlines the diagnostic pathway using the patient’s history, physical examination and ultrasound examination. It is important to correlate the clinical assessment with the imaging signs. It is also important to treat the patient and not the images as there may be abnormalities detected on imaging that are not symptomatic. The article covers the important diagnosis of subdeltoid subacromial bursitis, glenohumeral joint capsulitis, calcific tendinosis, acromioclavicular joint osteoarthritis and long head of biceps tendinosis. It will guide the reader in how to use the findings to treat, using ultrasound-guided injection and other techniques, including steroid injections, hydrodilatation, barbotage and extracorporeal shockwave treatment. These are discussed with the knowledge from over 30 years of experience with a literature review evidential support. I have included tips to make these procedures more effective in treatment and final outcome. There is discussion regarding the use of steroid injections in the presence of a rotator cuff tear and how to proceed if the patient has more than one disease process. The sensible use of steroids and local anesthetics are included, bearing in mind that lidocaine and high concentrations of long-acting local anesthetics are chondrotoxic and should not be injected into joints.

76-Year-Old Man With New Bilateral Shoulder Pain

76-Year-Old Man With New Bilateral Shoulder Pain

Intra-articular injection of botulinum toxin type A for shoulder pain in glenohumeral osteoarthritis: a case series summary and review of the literature.

IntroductionShoulder pain is one of the most common musculoskeletal diseases, and can be due to glenohumeral osteoarthritis, rotator cuff tear, impingement, tendinitis, adhesive capsulitis, and subacromial bursitis. Several therapies have been proposed, including steroids, nonsteroidal anti-inflammatory drugs, intra-articular injections, and physical therapies. Many published studies have reported on the employment of botulinum toxin type A (BoNT-A) to reduce pain in subjects with neurological and musculoskeletal diseases by inhibiting substance P release and other inflammatory factors.MethodsIn the present article, we briefly update current knowledge regarding intra-articular BoNT therapy, reviewing existing literature on intra-articular use of BoNT-A, including nonrandomized and randomized prospective and retrospective cohort studies and case series published from December 1989 to November 2017. We also describe a case series of six subjects treated with intra-articular injection of incobotulinumtoxin A for the treatment of pain deriving from osteoarthritis.ConclusionIntra-articular BoNT-A is effective and minimally invasive. Pain reduction with an increase in shoulder articular range of motion in our experience confirms the effectiveness of BoNT-A injection for the management of this syndrome.

Os Acromiale in Professional Tennis Players.

Background:Os acromiale is a rare condition mostly reported in the literature through case reports, imaging studies, or reports of surgical treatment. This condition is the result of nonunion of growth plates of the acromion during the natural developmental process that occurs between 15 and 25 years of age. Its incidence is low, and few studies are available in the literature on athletes with high functional demands, and particularly on athletes within a specific sport.Purpose:To collect epidemiological data and to report the amount of time out of play as well as the type of treatment and its efficiency in professional tennis players.Study Design:Case series; Level of evidence, 4.Methods:We performed a retrospective study using the medical data of athletes within our national tennis league who complained about their shoulder between 2011 and 2016. Nine professional tennis players (mean age, 20 years) with painful shoulders were diagnosed with os acromiale; 3 of them played at an international level, with the other 6 playing at a national level. The diagnosis was confirmed using radiography, including the axillary view, and magnetic resonance imaging (MRI). One female player had associated subacromial bursitis.Results:All cases of os acromiale were classified as involving the mesoacromion, following the Lieberson classification. No patient underwent surgery, and no patient was treated with local or subacromial infiltration. Patients stopped competition and training throughout the rehabilitation period. All patients received medical treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), ice, and physical therapy with a specific rehabilitation program. All athletes returned to their former level of play after a mean of 37 days. No patient suffered from recurrent pain. One patient underwent MRI after 2 years, showing a normal bone signal and complete healing of the acromion.Conclusion:Conservative treatment including NSAIDs, rest, ice, and physical therapy allowed for good recovery and return to the former level of play. Surgical treatment is usually not indicated for os acromiale in the professional tennis player.

Precontoured Clavicular Locking Plate with Broad Lateral End: A Newly Designed Plate for Lateral Third Clavicle Fractures.

Introduction: Various treatment modalities are available but no consensus has been reached for optimal treatment of lateral third clavicle fractures. Precontoured locking plates with broad lateral end for multiple screws fixation is a newly designed plate for lateral third clavicle fractures. The objective of our study was to analyse the functional outcomes as well as complications of this technique in a significant number of cases with long follow-up duration.Materials and Methods: Forty-six patients with distal third clavicle fractures were treated by precontoured clavicular locking plate with broad lateral end. Functional outcomes were assessed on the basis of Constant-Murley Shoulder Outcome Score and University of California, Los Angeles (UCLA) Shoulder Rating Score, active shoulder range of motion, time for fracture union and coraco-clavicular distance.Results: The mean Constant-Murley score was 92.56±4.47 (range: 79-98) for injured side and 96.22±2.23 (range: 90-100) for normal side with p-Value 0.56. Mean coraco-clavicular distance at final follow-up was 10.52±1.13 mm (range 9.7 to 11.7 mm) in injured side and 10.25±0.98 mm (range 9.6 to 11.2 mm) in normal side. Mean UCLA Shoulder Rating Score was 32.55±2.12 (range: 27-34) for injured side and 33.46±1.88 (range: 31- 35) on normal side with p value 0.58. No major complications that necessitated revision of surgery occurred in our study.Conclusion: This newly designed plate seemed extremely useful in successful union of lateral third clavicle fractures, with reduced rate of complications like fixation failures, iatrogenic rotator cuff injury, AC joint osteoarthritis and sub-acromial bursitis, with good functional outcomes.

Shoulder MRI Abnormalities in Asymptomatic Little League Baseball Players.

Background:Youth baseball is extremely popular in the United States, but it has been associated with shoulder pain and injury. The incidence of shoulder abnormalities in this athletic population has yet to be defined.Purpose:To examine abnormalities noted on magnetic resonance imaging (MRI) in the shoulders of asymptomatic Little League baseball players and to correlate these findings with the players’ throwing history and physical examinations.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 23 Little League baseball players aged 10 to 12 years were recruited. All players underwent a comprehensive physical examination and responded to a questionnaire addressing their playing history and any arm or shoulder pain. Bilateral shoulder MRIs were performed and read in a blinded manner by 2 radiologists. Responses on the questionnaire and physical examination findings were compared between participants with and without positive MRI findings through use of chi-square test and analysis of variance.Results:The dominant arm was 8.5 times more likely to have an abnormality on MRI compared with the nondominant arm. In all, 12 players (52%) had 17 positive MRI findings in their throwing shoulder that were not present in their nondominant shoulder. These findings included edema or widening of the proximal humeral physis (n = 5), labral tear (n = 4), partial rotator thickness tear (n = 4), acromioclavicular joint abnormality (n = 2), subacromial bursitis (n = 1), and cystic change of the greater tuberosity (n = 1). Two primary risk factors were associated with an abnormal MRI: year-round play and single-sport athletes focusing solely on baseball (P < .05). Players with no risk factors, 1 risk factor, and both risk factors had a 25%, 71%, and 100% chance, respectively, of having an abnormal MRI. A majority of players (61%) had previously experienced shoulder pain, especially pitchers throwing curveballs and sliders (P < .05), but this was not associated with an abnormal MRI.Conclusion:Abnormalities seen on MRI involving the shoulder are common in Little League baseball players, especially those who are single-sport athletes playing year-round.

Ultrasonography and magnetic resonance imaging changes in patients with polymyalgia rheumatica treated by tocilizumab

BackgroundThis study assessed inflammatory changes using ultrasound (US) and magnetic resonance imaging (MRI) in patients taking tocilizumab for polymyalgia rheumatica (PMR).MethodsEighteen patients were included in the prospective open-label TENOR study and received three tocilizumab infusions, without corticosteroids. B-mode and power Doppler US and MRI (T1 and T2-short time inversion recuperation weighted sequences) of the hips and shoulders were performed at weeks 0, 2, and 12. Subacromial, trochanteric, and iliopsoas bursitis and intraarticular glenohumeral and coxofemoral effusions/synovitis were scored from 0 to 3. Changes over time and US–MRI correlations were evaluated.ResultsAt baseline, the proportions of shoulders and hips with bursitis were 93 and 100% by MRI and 61 and 13% by US; and the corresponding proportions for intraarticular effusions/synovitis were 100 and 100% by MRI and 57 and 53% by US. Imaging findings did not improve during the first two treatment weeks. From baseline to week 12, bursitis improved significantly at all four joints by MRI (P = 0.005) and US (P = 0.029) and intraarticular effusions/synovitis by US only (P = 0.001). The proportion of abnormalities that improved by week 12 was 42% by MRI and 37% by US. MRI detected bursitis in a larger proportion of hips (73% versus 13%) and US in a larger proportion of shoulders (57% versus 28%), whereas no difference was found for intraarticular effusions/synovitis. At baseline, agreement between US and MRI findings was poor.ConclusionsUS and MRI showed significant improvements in inflammatory lesions during tocilizumab treatment of PMR.

Clinical utility of ozone therapy for musculoskeletal disorders.

Oxygen-ozone (O3) therapy serves as an alternative medical technique that increases the oxygen in the body along with the introduction of O3. O3 therapy has finally reached a level where the biological mechanisms of action have been understood, showing that they are in the domain of physiology, biochemistry, and pharmacology. Few clinical applications have been reviewed here as well as exemplifying that O3 therapy is particularly useful in musculoskeletal disorders. In the therapeutic range, O3 can be used as a more effective and safe substitute of standard medications. O3 therapy has been used for many years for its ability to inactivate various viruses, cancer, and acquired immune deficiency syndrome but is now making strides in the treatment of musculoskeletal disorders such as rheumatoid arthritis, lumbar facet joint syndrome, subacromial bursitis, carpal tunnel syndrome, osteoarthritis, hip bursitis, shoulder adhesive capsulitis, herniated disc, and temporomandibular joint disorder.

Risk of bursitis and other injuries and dysfunctions of the shoulder following vaccinations.

While vaccination injection site adverse reactions are usually mild and transient in nature, several cases of bursitis and other shoulder injuries have been reported in the medical literature. However, these lesions are not included in vaccine label inserts. To identify the characteristics of post-vaccination shoulder injuries and those of patients and involved vaccines, as well as their potential causes, a systematic review of the cases of vaccination-related bursitis and other shoulder injuries reported in the literature and notified to the Spanish Pharmacovigilance System database (FEDRA) have been conducted. We found 45 cases of bursitis and other shoulder injuries that appeared following the vaccine intramuscular injection given into the deltoid muscle (37 from the systematic review of the literature, and 8 from the scrutiny in the Spanish Pharmacovigilance System database, FEDRA). All the patients were adult, 71.1% females, with a mean and median age of 53.6years (range: 22-89). The most frequently involved vaccines were influenza and pneumococcal vaccines, respectively; followed by diphtheria-tetanus-pertussis, diphtheria-tetanus toxoid, human papillomavirus, and hepatitis A vaccines. The most frequent shoulder lesion was bursitis. Most of patients required medical care due to severe local pain and arm mobility restriction. In a majority of cases, symptoms started 48h post vaccination. Subdeltoid or subacromial bursitis and other shoulder lesions may be more common than suspected. Such lesions predominantly affect women. The cause may be related to antigens or adjuvants contained in the vaccines that would trigger an immune or inflammatory response. However, they are more likely to be the consequence of a poor injection technique (site, angle, needle size, and failure to take into account patient's characteristics, i. e., sex, body weight, and physical constitution). Therefore, vaccination-related shoulder injuries would be amenable to prevention.

Ultrasound-guided injections in primary care: evidence, costs, and suggestions for change.

Musculoskeletal (MSK) ultrasound has been used increasingly over the past decade, by non-radiologist hospital doctors, extended scope physiotherapists (ESPs), and to a lesser extent by GPs in primary care, both for diagnostic purposes and to guide therapeutic interventions. The reduction in equipment costs, together with improved image resolution and an increase in educational opportunities, seem to have facilitated these changes. MSK ultrasound is a highly effective diagnostic modality and is regularly used in secondary care to guide MSK interventions including joint and soft-tissue injections. Recent evidence, based on large randomised controlled trials (RCTs) and meta-analyses, demonstrates improved accuracy, efficacy, and cost-effectiveness of ultrasound-guided joint and MSK soft-tissue injections when compared with landmark-guided injections (LMGIs). In 2015 the American Medical Society for Sports Medicine (AMSSM) published a position statement reviewing the current evidence for ultrasound-guided injections (USGIs), focusing on the accuracy, efficacy, and cost-effectiveness of these interventions.1 It demonstrated high-quality evidence that USGIs are more accurate than ‘blind’ or LMGIs and ‘good’ evidence that USGIs are more effective than LMGIs specifically for large joints, inflamed joints, subacromial bursitis, carpal tunnel syndrome, and de Quervain’s tenosynovitis (Figure 1). There was also limited evidence …