Percutaneous Interventions in the Management of Shoulder and Scapula Conditions

Educational Objectives

The goal of this program is to improve the diagnosis and management of shoulder pathology. After hearing and assimilating this program, the clinician will be better able to:

1. Select appropriate modalities to guide therapeutic injections in the shoulder.
2. Weigh the risks and benefits of injectates for the management of pathologic conditions of the shoulder.
3. Optimize the use of traditional and novel percutaneous interventions to manage shoulder and scapular conditions.

Summary

Guiding injections: palpation of superficial landmarks — classic technique; ultrasonography — more appropriate; portable; hand-held devices available; superficial anatomy of shoulder facilitates visualization of structures down to details at submillimeter level; studies found ultrasonography allows better accuracy of injection into spaces of joints, biceps interval, and subacromial-subdeltoid bursa (SSDB) compared with palpation; fluoroscopy — accuracy greater compared with palpation; patient exposed to ionizing radiation; cost of maintenance and operation higher compared with ultrasonography; ultrasonography (continued) — good ergonomics and selection of needle important; superficial anatomy of shoulder allows use of shorter needles of smaller gauge (comfort greater)

Injected agents: volume — varies widely; 3 to 6 mL usual volume injected into glenohumeral joint or subacromial bursa; contents — vary widely (based on pathology and goals); corticosteroid most prevalent; other treatments include dextrose prolotherapy and hyaluronic acid viscosupplementation

Pathology of rotator cuff: prevalence of tendinosis and tearing highest (pathology and location vary); selecting appropriate target structure important; tendonitis refers to active inflammatory process; tendinosis and tendinopathy describe general pathologic conditions; process usually degenerative over time; impingement can involve SSDB or subcoracoid bursa; dynamic cuff impingement can occur under acromion; additional pathologies include tears, calcific tendinosis and tendonitis, and bursitis

Injection of SSDB: do not inject agent into intact rotator cuff; corticosteroid can cause degeneration if deposited into tendon; SSDB overlying rotator cuff most often targeted; use liner probe deep to deltoid muscle in peribursal fat for visualization; injections guided with ultrasonography more accurate compared with palpation (accuracy ≤100% in some studies); improvement of pain and functional motion greater with ultrasonography

Corticosteroids: Cochrane Review (Buchbinder et al 2003) found corticosteroids provide short-term benefit; speaker uses injections of corticosteroids as adjunctive therapy to facilitate PT; studies found 2 or 3 injections not more useful than single well-guided injection; other studies found detrimental effects; after single injection in rat model, stiffness of rotator cuff tendon decreased 32%; maximal load bearing decreased 27%; stiffness and load bearing decrease further with additional injections

Shams et al (2016): compared subacromial injection of platelet-rich plasma (PRP) with corticosteroid in patients with symptomatic partial tears of rotator cuff; found both injectates provided early relief of pain and improvement in function; benefit of PRP greater compared with corticosteroid at 12 wk; outcomes similar at 6 mo; PRP effective and potentially safer than corticosteroid

Calcific tendinosis of rotator cuff: fibrocartilaginous metaplasia after partial tear of rotator cuff; tear fills with calcium hydroxyapatite instead of collagen and cells of tendon; may be asymptomatic; appropriate management begins with initiation of PT; percutaneous intervention can help alleviate symptoms if PT painful; calcifications may be hard and mineralized, softer, or fluid; supraspinatus tendon affected in ≈80% of cases, infraspinatus in 15%, and teres minor in 5%; arthroscopy classic intervention; studies found ultrasound-guided percutaneous aspiration and lavage less invasive, potentially quicker, and possibly associated with fewer complications than arthroscopy; outcomes good; ultrasonography used to identify calcifications (may not reveal full depth of calcification); overlying SSDB anesthetized; using only one pass of needle appropriate when calcifications well encapsulated and distinct from tendon; 18-G needle inserted into calcification; normal saline pulsed in to debulk mass; double-needle approach more appropriate in nonclosed systems; injected fluid withdrawn with second needle in gravity-dependent position; outcomes of decompression paired with injection of corticosteroid good; study found outcome better for aspiration and lavage plus corticosteroid compared with aspiration and lavage alone

Anterior glenohumeral joint: common site of injection to treat labral tears and glenohumeral osteoarthritis; anterior approach allows injection into joint space and SSDB; posterior approach appropriate to target glenohumeral pathology, more accessible, and well tolerated; useful for glenohumeral osteoarthritis, adhesive capsulitis, and management of labral tears and degenerative diseases; studies found ultrasonography more accurate and effective than palpation

Adhesive capsulitis: inflammatory process restricts motion; prevalence highest in inferior glenohumeral ligament; injection of corticosteroid effective; studies found mechanical distention of joint with high volume can stretch ligaments and improve range of motion (volume injected varies among studies); injection to failure can decrease level of pain and increase range of motion and functional scores; use of high-volume injectate not necessarily superior to corticosteroid; can provide additional option

Cystic pathology: ultrasonography useful for identification of cystic and irregular pathology of shoulder; glenoid paralabral cyst may be associated with rent in glenoid labrum; can compress suprascapular nerve

AC joint: reproducible findings of palpation challenging; use ultrasonography to guide insertion of needle and injectate into AC joint; space thin (eg, osteoarthritis); step-down approach from outside plane facilitates entry into joint

Proximal long-head biceps tendon: accuracy in determining location for needle using palpation low; using ultrasonography ≤90%; ascending branch of anterior circumflex humeral artery runs along biceps (potential for intravascular injection)

Blunt-needle device: ultrasonography waves delivered through needle into tissue; tissue vibrates at frequency that spares healthy tendon and disrupts immature type 3 collagen and other tissues; saline injected through hub and aspirated through sheath

Prolotherapy (proliferative therapy): good outcomes reported; use of dextrose solution most prevalent; Bertrand et al (2016) assessed relief of pain in patients with tendinosis of rotator cuff; compared injections of dextrose with injections of saline and sham injections (superficial saline); dextrose and saline effective at 3 mo (sham injections provided some benefit); found better improvement of pain at 9 mo with dextrose compared with saline; prolotherapy effective, but not necessarily more effective than dry needling or sham procedures; often not reimbursed by insurers

Readings

Bertrand H et al: Dextrose prolotherapy versus control injections in painful rotator cuff tendinopathy. Arch Phys Med Rehabil 2016 Jan;97(1):17-25; Buchbinder R et al: Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev 2008 Jan 23(1):CD007005; Buchbinder R et al: Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003 (1):CD004016; Neviaser AS et al: Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg 2011 Sep;19(9):536-42; Shams A et al: Subacromial injection of autologous platelet-rich plasma versus corticosteroid for the treatment of symptomatic partial rotator cuff tears. Eur J Orthop Surg Traumatol 2016 Dec;26(8):837-42.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Lueders was recorded at the Comprehensive Musculoskeletal Center Update: Shoulder Diagnosis and Management at Northville, held December 2, 2017, in Northville, MI, and presented by the University of Michigan Medical School. For information about upcoming CME opportunities from this sponsor, please visit ocpd.med.umich.edu/cme. The Audio Digest Foundation thanks the speakers and the University of Michigan Medical School, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR410602

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.