Why Ultrasound-Guided Shoulder Injections Outperform Landmark-Based Techniques
Joint or soft-tissue injections are commonly used to treat shoulder issues, but not all techniques are equally effective. Traditionally, landmark-guided injections were the standard based on palpation and anatomical landmarks. However, ultrasound-guided injections have gained popularity for their superior accuracy and efficacy, especially in the shoulder joint. Here’s why US-guided shoulder injections are a better option for clinicians looking to improve patient outcomes.
Accuracy: Ultrasound vs. Landmark-Guided Injections
The shoulder is complex, with areas like the subacromial space, biceps tendon sheath, acromioclavicular (AC) joint, and glenohumeral (GH) joint posing unique challenges for needle placement. Furthermore, essential nerves and blood vessels must be avoided.
Studies consistently show that ultrasound-guided injections are more accurate than landmark-guided ones. Two Systematic Reviews revealed significant improvements in accuracy for ultrasound-guided injections in the AC joint (93.6% vs 68.2%), biceps tendon sheath (86.7% vs 26.7%), GH joint (92.5% vs 72.5%), and subacromial space (100% vs 72%).(1,2)
Efficacy: Better Pain Relief and Functional Improvement
Compared to landmark-based techniques, ultrasound-guided injections are also linked to better pain relief and functional improvements. A 2022 systematic review in the Journal of Ultrasound examined 18 randomized controlled trials with 1,010 patients and found that ultrasound-guided cortisone injections resulted in more significant improvements in pain (via visual analogue scale), shoulder function, and shoulder abduction for various shoulder problems.(3)
Example: Subacromial Injection
Subacromial injections are typically used to treat bursitis, shoulder impingement, rotator cuff tendinopathy, and adhesive capsulitis. Ultrasound guidance improves accuracy and helps differentiate the source of shoulder pain. Patients receiving ultrasound-guided injections for subacromial space experienced significantly better pain relief and functional improvement six weeks post-injection.(3) Given the small size and location of the subacromial bursa (1-3 mm thick, 30 mm deep), even slight needle misplacement of less than a degree of angulation may reduce the effectiveness of the injection.(4,5) Accidental injection of the steroid in a muscle or tendon increases the risk of tendon rupture. Ultrasound guidance minimizes this risk and enhances outcomes.(3)
Conclusion: How I Can Help Your Practice
Ultrasound-guided shoulder injections significantly advance patient care over traditional landmark-based methods: offering superior accuracy, fewer complications, and better clinical outcomes. At Arthur Musculoskeletal Health, I frequently consult on referrals for rotator cuff tendinopathy, glenohumeral osteoarthritis, calcific tendonitis, frozen shoulder, and biceps tendonitis.
One common issue that comes up is patients concerned about steroid complications for their rotator cuff problems. Hyaluronic acid injections now offer an effective alternative to steroids for rotator cuff pathology, as shown in a 2023 systematic review of 1,773 rotator cuffs from 18 studies.(6) The benefits of hyaluronic acid were similar to steroids at the 1 and 3-month mark, without exposing the patient to the usual risks associated with steroids, such as tendon ruptures or hyperglycemia. Improvements with hyaluronic acid were also superior to PRP and physiotherapy at the 1-month mark but not at the 3-month mark.(6)
Referrals from Ontario physicians are most welcome if I can assist in providing precise and effective shoulder injections for your patients.
References:
- Aly A, Rajasekaran S, Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med. 2015;49(16):1042-1049.
- Saha, P., Smith, M., & Hasan, K. (2023). Accuracy of Intraarticular Injections: Blind vs. Image Guided Techniques—A Review of Literature. Journal of Functional Morphology and Kinesiology, 8(3), 93. https://doi.org/10.3390/jfmk8030093
- ElMeligie MM, Allam NM, Yehia RM, et al. Systematic review and meta-analysis on the effectiveness of ultrasound-guided versus landmark corticosteroid injection in the treatment of shoulder pain: an update. J Ultrasound. 2023;26:593-604. doi:10.1007/s40477-022-00684-1.
- Sardelli M, Burks RT. Distances to the subacromial bursa from 3 different injection sites as measured arthroscopically. Arthroscopy. 2008 Sep;24(9):992-6. doi: 10.1016/j.arthro.2008.04.070. Epub 2008 Jun 16. PMID: 18760205.
- White EA, Schweitzer ME, Haims AH. Range of normal and abnormal subacromial/subdeltoid bursa fluid. J Comput Assist Tomogr. 2006 Mar-Apr;30(2):316-20. doi: 10.1097/00004728-200603000-00030. PMID: 16628056.
- Bansal S, Raja BS, Niraula BB, et al. Efficacy of hyaluronic acid in rotator cuff pathology compared to other available treatment modalities: A systematic review and meta-analysis. J Orthop Rep. 2023;2(3):100157. doi:10.1016/j.jorep.2023.100157.
This blog from Arthur Musculoskeletal Health is a series of free online medical education posts dedicated to providing online primary care education for physicians, nurse practitioners, physician assistants, residents, and medical students. This blog is not intended to be medical advice for patients; please see your legally qualified medical practioner for your medical condition(s). The information provided is for general and informational purposes only and is not meant to diagnose, treat, or prevent any medical condition. The post information is stated in an individual capacity, and not as a part of my duties at my hospital or academic institutions.