Ultrasound-guided steroid injection
What is ultrasound?
Ultrasound is high frequency sound waves produced by a special machine. They can penetrate the skin providing very useful images of the deep tissues within the body. It is a harmless way of imaging and it is extremely useful in assessing various musculoskeletal conditions that can involve tendons, muscles, joints and the adjacent soft tissues. Unlike x-rays, ultrasound does not involve exposure to radiation or any harmful side effects.
What is a steroid/cortisone injection?
Steroid (also called cortisone) are anti-inflammatory medicines that can help relieve pain and inflammation in a specific area of the body. They can be injected into a joint to help relieve pain, usually in the context of arthritis. This is referred to as “an intra articular steroid injection”.
They are also used to treat other inflammatory conditions like bursitis (inflammation of sac like fluid collections present in different parts of the body) and tendonitis (tendon inflammation).
Steroid injections can’t treat the underlying cause of your condition, but they can treat the symptoms. They are potent anti-inflammatory medicines that should reduce the inflammation, and in turn the pain in that specific area. The Commonly used types of steroid injections are hydrocortisone, triamcinolone and methylprednisolone.
A steroid injection normally takes a few days to start working. The effect usually wears off after a few months. The injections usually also contain a local anaesthetic, that provides immediate pain relief lasting a few hours.
What is the benefit of having an ultrasound guided injection vs. blind injection?
Ultrasound is very useful to assess the joints, tendons and ligaments for any suspected injury or inflammation. In addition, it allows for direct visualisation of the needle to ensure the steroid medication is injected into the exact targeted site.
There is a significant evidence that ultrasound guided injections provide better levels of pain relief and longer effects compared with injections done without imaging guidance. This is because ultrasound guidance allows for accurate placement of the needle and thus delivery of the medicine to the exact site of pathology. Performing the injection under ultrasound guidance allows for visualisation of the adjacent structures and reduces the risk of tissues injury at the injection site.
Baker’s cyst aspiration and steroid injection
What is a Baker’s cyst?
A Baker’s cyst is a swelling at the back of the knee due to fluid accumulation. It is usually associated with build-up of excess fluid within the knee joint, which is referred to as “knee joint effusion” as some of the fluid may be pushed at the back of the knee. A Baker’s cyst is usually secondary to a knee joint condition that results in build-up of fluid, such as knee joint inflammation (for example in conditions like Rheumatoid arthritis), knee joint wear and tear (osteoarthritis), meniscal and cartilage tears.
What are the symptoms of Baker’s cyst?
- Swelling at the back of the knee that can change in size.
- If large enough, it can lead to pain and restriction of movement, particularly when straightening the knee.
- A Baker’s cyst can sometimes leak (usually referred to as a ruptured Baker’s cyst). This can present with sudden pain and swelling in the calf. If these symptoms occur, it is important to see a doctor to rule out a more serious condition called deep vein thrombosis or “DVT”, which refers to clot within the deep veins in the leg.
What is ultrasound guided Baker’s cyst aspiration and steroid injection
If the cyst is large and causing significant symptoms, then ultrasound guided aspiration can be performed. It is important to highlight that the cyst is connected to the knee joint and therefore it may reoccur especially if there is generalised build-up of fluid and an there is an underlying cause for this within the knee joint (for example knee osteoarthritis or meniscal tear). An ultrasound guided steroid injection to the cyst at the time of the aspiration would help to reduce the chance of cyst recurrence.
Ultrasound guided high volume Achilles tendon injection
What is Achilles tendinopathy?
Achilles tendinopathy refers to inflammation of the Achilles tendon. Achilles tendon issues can be categorised into insertional (lower down) and non-insertional (mid-portion) problems. It can be very restrictive to movement and activities. Achilles tendinopathy is reported in sport people (particularly runners) but also in people with sedentary life style.
What is ultrasound guided high volume Achilles tendon injection?
Ultrasound guided high volume Achilles tendon injection is a treatment option for mid portion Achilles tendinopathy. In this procedure, the radiologist uses ultrasound guidance to inject a mixture of medicine (usually contains numbing medication, normal saline/sterile water and sometimes low dose steroid). This is injected accurately under ultrasound guidance to separate the Achilles tendon from the deep fat pad. There is evidence that patients with Achilles tendinopathy develop small nerves that runs from the fat pad into the Achilles tendon; and these nerves contribute to the pain sensation. This procedure aims to destroy these nerves and thus reducing the pain.
Ultrasound guided Barbotage/lavage procedure for rotator cuff calcific tendonitis.
What is calcific tendonitis?
Calcific tendonitis (also known as calcific tendinopathy) results from deposition of calcium material within the rotator cuff tendons. The rotator cuff tendons consist of 4 tendons (the supraspinatus, infraspinatus, subscapularis and teres minor tendons). They form a complete cuff of tissue that surrounds the shoulder joint and play a vital role in shoulder movement and stability.
The exact aetiology of calcific tendinitis is not fully understood. One school of thought believe it is caused by transformation of the cells that produce tendon tissue into different type of cells that produce cartilage. This in turn can result in calcium deposition within the tendon. It is more common in diabetic patients and in woman between the age of 40 and 60 years. It is also more common in people who use their arm excessively like manual workers and athletes. Deposition of calcium is also reported following trauma.
What are the symptoms of calcific tendonitis?
Calcific tendonitis can result in sudden onset, severe pain in the shoulder especially when the calcium material irritates the subacromial bursa. The pain can refer down the arm and interfere with sleep. It can also cause severe restriction to movement in all directions, and therefore it can mimic frozen shoulder.
What is ultrasound guided barbotage-lavage?
In this procedure, Aspiration or breaking down of the calcium material is accurately attempted under ultrasound guidance using a special large needle. This is combined with a subacromial bursa steroid and local anaesthetic injection. The lavage and breaking down of the calcification will help the body to get rid of the calcium deposit, and the subacromial bursa injection will help settle down the bursal inflammation. Numbing medication (local anaesthetic) injection is usually used before the procedure to numb the skin and the subacromial bursa.
Ultrasound guided ganglion cyst aspiration and steroid injection
What is a ganglion cyst?
Ganglion cysts are thin-walled fluid-filled sacs most commonly seen around the wrist joint but they can occur any part of the body. They are usually seen close to joints or tendons as they usually arise from the joint or the tendon sheath (the covering of the tendon). The exact cause is not certain but they are thought related to degenerative changes to the joint or tendon resulting in increase in fluid production which can result in these ganglion cysts. The fluid is usually thick and jelly like.
What are the symptoms of a ganglion cyst?
- A ganglion cyst usually results in a lump at the wrist or the foot. The lump can be hard and can change in size or disappear.
- If the ganglion cyst is large enough, it can cause pressure upon any adjacent structures. It can result in pain or numbness if it is causing pressure upon a nerve within the wrist.
What is ultrasound guided ganglion cyst aspiration/steroid injection
Ganglion cysts themselves are harmless. They can cause pain or discomfort depending on their location. Treatment is not usually indicated unless the cyst is causing symptoms or the patient is concerned about the appearance.
Aspiration of the cyst under ultrasound guidance is an option. A large needle is used as the fluid is usually thick and gelatinous. This procedure is more successful with larger cysts. It is important to know that there is high possibility of recurrence of the cyst after aspiration. Injecting a small dose of steroid after the aspiration aims to reduce the inflammation in the area and reduce the chance of ganglion cyst recurrence but this remains a possibility. Using ultrasound guidance will ensure accurate needle placement and avoid injuring any important structures adjacent to the ganglion cyst.
Ultrasound guided shoulder hydrodilatation for treatment of frozen shoulder.
What is Frozen shoulder?
Frozen shoulder (or adhesive capsulitis) is a condition where there is generalised inflammation of the shoulder joint capsule (the soft tissues that surround the shoulder joint). It can happen secondary to various causes including trauma and surgery, and it is also more common in people who have diabetes but sometimes no obvious cause is found. It is more common in people over the age of 40.
What are the symptoms of Frozen shoulder?
- Patients usually experiences severe pain and significant reduction of the shoulder movements, which can be limiting to the simple daily activities.
- Patient may also have shoulder pain at night that can disrupt sleep.
- Usually the symptoms improve without treatment but this can take a long time (up to a few years).
How is frozen shoulder diagnosed?
Frozen shoulder is generally a clinical diagnosis. Imaging is mainly done to rule out other causes for shoulder pain like rotator cuff tear, shoulder osteoarthritis and shoulder calcification (calcific tendonitis). An X-ray will be normal in frozen. MRI can be helpful in the diagnosis as it can show some signs suggestive of frozen shoulder changes like capsular thickening and inflammation. Ultrasound and MRI can assess for presence of rotator cuff tear or subacromial bursitis.
What is shoulder hydrodilatation?
Hydrodilatation or hydrodistension is a special procedure used to treat frozen shoulder/adhesive capsulitis. It can be considered if simple treatment (like physiotherapy and anti-inflammatory tablets) are not effective.
It involves injecting high volume of sterile (clean) water with steroids and numbing medications inside the shoulder joint. This aims to distend the inflamed and thickened joint capsule and to reduce the inflammation via the steroids. Hydrodistension needs to be done under imaging guidance (either ultrasound or x-ray/fluoroscopy). Evidence is encouraging and currently hydrodistension is an established treatment for the management of frozen shoulder. It is important to follow shoulder hydrodistension procedure by a specialist physiotherapy program to enhance the results of the procedure.