Accuracy of in vivo palpation-guided acromioclavicular joint injection assessed with contrast material and fluoroscopic evaluations.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of in vivo acromioclavicular (AC) joint injections without fluoroscopic guidance and assess whether patient demographics affected the accuracy of injections. MATERIALS AND METHODS: A consecutive cohort of patients who presented with painful acromioclavicular joints was prospectively evaluated. All patients had clinical and radiographic evidence of AC arthritis, had failed conservative measures, and thus had received intraarticular corticosteroid injections. All injections were performed by experienced fellowship-trained musculoskeletal radiologists and by blinded digital palpation technique. Accuracy of injections was assessed with biplanar fluoroscopic views. RESULTS: Forty-one AC injections in 22 males and 16 females with a mean age of 51 years (range 18 to 78) were identified. Twenty-three injections were in the right shoulder and 18 in the left. Only 15 injections were confirmed to be in the intraarticular AC joint, yielding an accuracy of 36.5%. There were no significant differences in the mean age (54 vs. 52 years; p = 0.58), male-to-female ratio (p = 0.73), and side of the injection between the accurate and inaccurate injections, respectively. CONCLUSION: Based on the findings of the present study, the authors encourage the use of image guidance for corticosteroid treatment of the AC joint. LEVEL OF EVIDENCE: Level IV Therapeutic Case Series.

Subacromial corticosteroid injection on poststroke hemiplegic shoulder pain: a randomized, triple-blind, placebo-controlled trial.

OBJECTIVE: To evaluate the effect of subacromial corticosteroid injection on hemiplegic shoulder pain (HSP). DESIGN: Multicenter, randomized, triple-blind, placebo-controlled trial. SETTING: Three primary and 1 university-affiliated tertiary-care hospitals. PARTICIPANTS: Poststroke HSP patients (N=58) with evidence of rotator cuff disorder. INTERVENTIONS: Participants were randomly assigned to receive ultrasound-guided subacromial injection with triamcinolone 40mg (treatment group, n=29), or lidocaine (placebo group, n=29). After a single injection, participants were followed up for 8 weeks. MAIN OUTCOME MEASURES: Visual analog scale (VAS) of the average shoulder pain level at day and night (VAS-day/night, the primary outcome measures), Modified Barthel Index, Shoulder Disability Questionnaire (SDQ), and angles of shoulder active range of motion (flexion, abduction, external rotation, and internal rotation) at pretreatment and weeks 2, 4, and 8 posttreatment. RESULTS: There was no significant difference between the 2 groups in the main outcome measures at pretreatment. Compared with the placebo group, VAS-day/night, SDQ, flexion, external rotation, and internal rotation showed significant improvement in the treatment group. CONCLUSIONS: To our knowledge, this is the first randomized, placebo-controlled study to assess the efficacy of subacromial injection in HSP patients with evidence of rotator cuff disorder. Subacromial corticosteroid injection showed improvement in pain, disability, and active range of motion, and the duration of its efficacy continued up to 8 weeks.

The long term effect of an intra-articular injection of corticosteroids in the acromioclavicular joint.

BACKGROUND: A prospective study was established to assess the effect of an intra-articular injection of corticosteroid and local anaesthetic into the acromioclavicular (AC) joint. METHODS: Fifty-eight patients with isolated AC joint symptoms were included. Clinical tests were repeated immediately following the injection, as well as at 1-month follow-up. If symptoms failed to improve at this time, arthroscopic surgery was offered. All other patients were dismissed from standard care and contacted for this study. Both American Shoulder and Elbow Surgeons (ASES) and University of California at Los Angeles (UCLA) scores were obtained at final follow-up. RESULTS: Sixteen patients had improved sufficiently. Between the 1 month and average final follow-up of 42 months, 1 patient had arthroscopic resection of the distal clavicle. Four of the 15 patients reported occasional mild pain. Average visual analogue scale (VAS) score for pain was 0.5 (0-3). Average ASES score was 94.1 (70-100) and average UCLA score was 33.9 (28-35). DISCUSSION: Pain relief achieved with an injection into the AC joint has both a diagnostic and therapeutic value. The decrease of pain with clinical testing affirms the correct position of the injection. Only a minority of patients has sufficient pain relief from the injection at 1 month follow-up; however, this is sustained at the longer-term follow-up in the patients that have a positive reaction. CONCLUSION: The diagnostic value of the injection of a local anaesthetic in the AC joint is immediate. Only 28% have a clear positive result at 1 month; but, this result is sustained at long-term follow-up. There were no complications.

The short term effects of a single corticosteroid injection on the range of motion of the shoulder in patients with isolated acromioclavicular joint arthropathy.

This study is aimed at evaluating the short-term effects of a single corticosteroid injection of the acromioclavicular joint on the range of motion of the shoulder joint using a three dimensional electromagnetic tracking system (FASTRAK) in patients with isolated unilateral acromioclavicular joint (ACJ) arthropathy. Eighteen patients (16 male, 2 female; mean age: 47.53 years), with isolated unilateral ACJ arthropathy were included in the study. Injection of the symptomatic ACJ with local anaesthetic and corticosteroid was performed under image intensifier guidance. Bilateral shoulder FASTRAK assessment before and two weeks after injection of the symptomatic ACJ was performed, measuring flexion/extension, anatomical abduction, scapular abduction and horizontal cross body adduction. Pain was measured using a visual analogue scale. There was a significant difference in the range of movement between the symptomatic and asymptomatic shoulder before the injection (p < 0.01). Range of extension and pain score of the symptomatic shoulder improved significantly (p < 0.05 and p < 0.001, respectively) after the injection. In patients with radiographical evidence of degenerative ACJ disease, there was also significant improvement in the range of horizontal flexion (p < 0.05). Injection of the ACJ with local anaesthetic and corticosteroid was found to produce short-term pain relief and partial improvement in the range of movement. FASTRAK is useful in the measurement and documentation of range of motion, and can be used to assess the treatment outcome in patients with isolated ACJ arthropathy.

[Somatostatin in peri-arthropathies of the shoulder: clinical effectiveness and tolerability after sub-acromial administration]. / La somatostatina nelle periartropatie della spalla: efficacia clinica e tollerabilità dopo somministrazione subacromiale.

In the last few years, the intra-articular administration of somatostatin, has been used in some diseases regarding rheumatology such as rheumatoid arthritis psoriatic arthritis and osteoarthritis, giving encouraging results. The objective of this study was to asses the efficacy and tolerability of subacromial-injection of somatostatin in 20 patients with painful shoulder. The study consisted of 3 injection administered every 4 days. The results revealed a significant improvement of the pain during active movement as well as joint excursion, and interference with daily activity immediately after the first injection. The good tolerability of the drug and the absence of unwanted side-effects allow us to foresee that the local-administration of somatostatin could be used in painful shoulder notably in those patients in which other drugs are not appropriate.

Common regional pain syndromes. II.

In subacromial bursitis, trochanteric bursitis and gluteal enthesopathy, large volume injections may be required to control symptoms--they should be backed up with advice on prevention of recurrence.

Manual physical therapy for injection-confirmed nonacute acromioclavicular joint pain.

STUDY DESIGN: Prospective single-cohort study. OBJECTIVES: To determine and document changes in pain and disability in patients with primary, nonacute acromioclavicular joint (ACJ) pain treated with a manual therapy approach. BACKGROUND: To our knowledge, there are no published studies on the physical therapy management of nonacute ACJ pain. Manual physical therapy has been successful in the treatment of other shoulder conditions. METHODS: The chief inclusion criterion was greater than 50% pain relief with an ACJ diagnostic injection. Patients were excluded if they had sustained an ACJ injury within the previous 12 months. Treatment was conducted utilizing a manual physical therapy approach that addressed all associated impairments in the shoulder girdle and cervicothoracic spine. The primary outcome measure was the Shoulder Pain and Disability Index. Secondary measures were the American Shoulder and Elbow Surgeon and global rating of change scales. Outcomes were collected at baseline, 4 weeks, and 6 months. The Shoulder Pain and Disability Index and American Shoulder and Elbow Surgeon scale values were analyzed with a repeated-measures analysis of variance. RESULTS: Thirteen patients (11 male; mean ± SD age, 41.1 ± 9.6 years) completed treatment consisting of an average of 6.4 sessions. Compared to baseline, there was a statistically significant and clinically meaningful improvement for the Shoulder Pain and Disability Index at 4 weeks (P = .001; mean, 25.9 points; 95% confidence interval [CI]: 11.9, 39.8) and 6 months (P<.001; mean, 29.8 points; 95% CI: 16.5, 43.0), and the American Shoulder and Elbow Surgeon scale at 4 weeks (P<.001; mean, 27.9 points; 95% CI: 14.7, 41.1) and 6 months (P<.001; mean, 32.6 points; 95% CI: 21.2, 43.9). CONCLUSION: Statistically significant and clinically meaningful improvements were observed in all outcome measures at 4 weeks and 6 months, following a short series of manual therapy interventions. These results, in a small cohort of patients, suggest the efficacy of this treatment approach but need to be verified by a randomized controlled trial. LEVEL OF EVIDENCE: Therapy, level 4.

Comparison of a novel direct measure of rapid pain intensity change to traditional serial 100 mm VAS measurement of pain intensity.

OBJECTIVES: Key diagnostic decisions often turn on measurement of change in pain intensity after diagnostic anesthetic blocks. This study aimed to introduce a new direct measure pain intensity change and compare it with percent change as calculated from the traditional preprocedure and postprocedure pain visual analog scales. METHODS: Shoulder pain patients enrolled in a diagnostic accuracy study comparing clinical variables with image-guided local anesthetic injections were assessed with both the traditional preprocedure and postprocedure visual analog scales and the new direct method. Percent change in pain intensity was calculated with both instruments and were compared using statistical methods. The percentage pain reduction used to classify patients as responders was 80%. RESULTS: Patients received anesthetic injections to targeted shoulder structures (N=146, 331 procedures). For data above the 80% pain reduction criterion, Lin Concordance statistic ranged from 0.22 to 0.55. Bland and Altman analyses revealed positive bias and the amount of reported pain reduction was higher with the traditional method. For data above the 80% pain reduction criterion, the bias was higher and ranged from 4.8% to 12.6%. CONCLUSIONS: The 2 methods are not interchangeable. The new method measures the pain intensity change dimension directly, whereas the traditional method estimates change indirectly by calculation. Face validity is better served by adopting the new method for decisions regarding whether a patient is a "responder" or "nonresponder" to diagnostic blocks. The traditional method should be retained for estimation of pain intensity preprocedure and the duration of pain relief postprocedure.

The infiltration of the AC joint performed by one specialist: ultrasound versus palpation a prospective randomized pilot study.

INTRODUCTION: The acromio-clavicular (AC) joint is very susceptible to degenerative processes that result in pain and functional impairment. One common modality of treatment has been local infiltration of the joint space. Although this procedure has produced notable positive results, needle misplacement occurs frequently. The aim of this investigation is to evaluate the effects of an intra articular infiltration by comparing precise needle placement into the joint space using high-resolution-ultrasound with the conventional palpation technique. METHODS: This prospective and randomized pilot study analysed 20 patients who were assigned either to the "ultrasound" or the "palpation" group. Clinical examinations were performed before treatment and at 1h, 1 week and 3 weeks after a single infiltration of local anaesthetic and corticoid carried out by one specialist. RESULTS: In both groups significant improvement in pain and function was obtained up to one-week post injection. Function remained significantly improved until the last follow-up and did not differ between the two groups. The agent was administered in all patients into the joint space in the ultrasound group. CONCLUSION: Ultrasound guided infiltration of the AC joint is an easily achieved procedure without any complications. However, clinical follow-up did not differ between free-hand and ultrasound-guided AC joint space infiltration.

[Conduction blocks in the complex treatment of humeroscapular periarthritis]. / Provodnikovye blokady v kompleksnom lechenii plechelopatochnogo periartrita.

The authors propose a method of treatment of humeroscapular periarthritis by high conduction blocks of the brachial plexus by supraclavicular approach. The influence of high conduction blocks of the brachial plexus on the peripheral circulation in the upper extremities has been studied. The results of the treatment of 192 patients with humeroscapular periarthritis (mostly) with neglected forms of the disease) are presented.

MRI features of the acromioclavicular joint that predict pain relief from intraarticular injection.

OBJECTIVE: Our objective was to evaluate the predictive value of various MRI findings in the acromioclavicular joint for pain relief after intraarticular injection. MATERIALS AND METHODS: The acromioclavicular joint of 50 patients (20 women, 30 men; mean age, 51 years; range, 25-75 years) was evaluated on MRIs of the shoulder. Osteophytes, subchondral cysts and irregularities, bone marrow edema, joint effusion, and joint capsule hypertrophy were assessed by two musculoskeletal radiologists in consensus. Local anesthetics were injected into the acromioclavicular joint with fluoroscopic guidance. Patients graded pain relief on a visual analogue scale (0-100%) after 15 min. The relationship between pain relief and MRI findings was assessed with the Mann-Whitney U test. Pain relief equal to or greater than 70% was rated as a positive response to the injection. This cutoff value was used to calculate sensitivity, specificity, accuracy, and predictive values of the various MRI findings in determining which acromioclavicular joints were responsive to joint injections. RESULTS: Mean pain relief after injection was 38%. Pain relief was significantly related to capsular hypertrophy (p = 0.007) and was equal to or greater than 70% in 11 patients. The sensitivity in diagnosing a successful injection (range, 9-82%) was highest for caudal osteophytes (82%) and capsular hypertrophy (73%). The specificity (range, 51-97%) was highest for subchondral cysts (97%), subchondral bone marrow edema (95%), and joint effusion (92%). CONCLUSION: Pain relief after intraarticular injection is significantly related to capsular hypertrophy diagnosed on MRI. MRI findings have a reasonable sensitivity and a high specificity in predicting relevant short-term pain relief after intraarticular injection.