Ultrasound Guided Cortisone Injections for Frozen Shoulder - SD

Introduction

Hi, and welcome to this lecture on diagnosing and treating frozen shoulder
by ultrasound guided cortisone injections.

My name is YRN Bnos.

I'm a physiotherapist and manual therapist working in the private practice
in the middle part of Norway.

Outside Heim with my colleague through the Garman week.

I teach courses in musculoskeletal ultrasound and guided procedures
through our company ultrasound trend log, mainly in Oslo.

Particularly during the last three years, we've had a lot of frozen shoulder patients
and therefore we would like to share this with you, our views and experiences
on this very challenging topic.

Opioid producer on this lecture is manual therapist, founder and manager
of body examination.com and excellent resource in clinical examination techniques.

We hope you will find this lecture useful.

Hello, my name Isru Demic.

I am the other member of Ultra trend lag and I also teach courses in ultrasound
with urine Buros.

I am a physiotherapist and a practitioner of clinical orthopedic medicine
by the principal of Dr. Ox.

I work at UAR Medical Center together with four general practitioners.

Frozen Shoulder Diagnosis and Treatment by Ultrasound Guided Cortisone Injections

We want to discuss the clinical signs in the diagnostics of frozen shoulder
to show that the condition is treatable.

Because research is scanned and contradictory, we want to show how to get
the injected material inside the capsule.

We think this is mandatory for an optimal response and when this is successful,
the improvement profile is also different from injections without ultrasound guidance.

Improvement Profile: Blind vs Ultrasound Guided Method

In our experience, the improvement profile blind versus ultrasound guided method.

For blind injection methods, often four to six injections are common.

Improvement often starts after two to three treatments.

For the ultrasound guided method, we find that one to three injections suffices
and improvement often is largest after the first injection.

Often one to two injections are enough.

Response to Treatment

A little bit about the response to treatment.

If the stiffness and range of movement is markedly diminished, increase in range
of movement will be slow, but the pain goes away or most of the pain goes away
and allows for a stretching regime to commence.

If the condition is treated in the early phase before the limitation in movement
is markedly lost, the range of movement may be regained more rapidly.

Hypothesis for the Difference

Some hypothesis for the difference, the ultrasound guiding enables hitting the target
almost all the time, and with mostly all of the injected fluid.

Hitting the large volume makes a smaller miss than if one uses, for example,
only one milliliter of cortisone, then everything is lost outside a capsule.

If you miss the large volume, say six to seven milliliters of zylocaine, 1%
and one milliliter triamcinolone hex acetonide, about seven eight milliliters in total
enables visual confirmation of hit and also retests show marked less pain.

Background

A little bit about the background.

Frozen shoulders are relatively rare, but have a prevalence of three to 6%.

Seeing three to six patients a year is common in the general practitioner's practice
or in the physiotherapy and manual therapy practice in Norway.

Circumstances has allowed us to see approximately a hundred to 120 frozen shoulder patients
the last two years, about 200 to 250 among the three of us.

Because of the ultrasound guidance, the diagnosis has gone from seeming quite hopeless
to be very interesting and satisfactory to treat.

We know that this contradicts some research but agrees with other studies.

For example, the one from colleagues from 2009, which treated 90 patients with one injection only
and with a very high success rate.

The situation might be summarized as there is little research on frozen shoulder.

There is conflicting attitude regarding the choice of treatment.

Those who do ultrasound guiding have a quite opposite view and find the condition
very satisfactory to treat.

Staging in Frozen Shoulder Development

There are some common staging in the frozen shoulder development and we have chosen
to pick res from 1975, which lists the painful stage from two and a half to eight months.

The stiffening phase four to 12 months, and the recovery phase from five to 24 months.

What is Capsulitis?

What is it really this capsulitis?

There is a real inflammation and a shrinkage of the joint capsule,
as we shall see later by athroscope.

You can see the inflammation.

There is a gradual stiffening of the joint mobility, reduced range of movement,
and often a capsular pattern that is more reduced lateral rotation than abduction
and then internal rotation in that pattern.

There is often a lot of resting pain and night pain and often severe pain at the range
of movement.

Isometric or dynamic resistance inside the comfort zone is not or very little painful.

Diagnosis

A little bit more about the diagnosis.

The diagnosis is mainly clinical.

In the initial phase, the diagnosis may be difficult.

Ultrasound may often show hyperemia in the rotator interval, medial to the biceps,
but remember that a lateral artery is perfectly normal lateral in the bicep screw.

Ultrasound might may show slight increase of fluid around the long head of the biceps,
maybe because arthritis is producing a certain hydrops, which overflows out the bicep shaft,
which is really an intraarticular structure.

MRI shows promising and improving diagnostic abilities.

For instance, by seeing thickening in the rotator interval.

Contemporary Definitions

Some common contemporary definitions, pain and stiffness is predominantly one shoulder
and restriction of passive movement more than 30 degrees in more than two planes.

There is limited lateral rotation, abduction and medial rotation in that pattern.

The end feel may be abrupt or with a lot of pain, it can be described as empty.

That means that you don't reach the end feel because it's too painful for the patient.

Often the patient has a characteristic of the pain locally and down the arm.

Some say that this is really omic characteristic of the disease.

The pain may be really intense for maybe half a minute after an abrupt movement.

There is none or significantly less pain on isometric tests in resting position.

Ultrasound signs of hyperemia in the rotator interval or slight extra fluid around long head
of biceps as earlier mentioned.

And we also mentioned the thickening of the capsule anteriorly by MRI etiology.

Etiology

A lot of capsulitis are idiopathic.

We don't know.

It may happen after surgical shoulder interventions, after trauma, even light or minor trauma.

It happens much more often in diabetics, in thyroid disease and in hyperlipidemia.

Some has suspected some unknown form of autoimmune disease.

Pathology

A bit more pathology.

The decrease in range of movement is caused by a process in the coraco humeral ligament.

Most likely in the anterior capsule.

Arthroscopically we see often a red or inflamed capsule.

There is often an increase in the type three collagen, similar changes as in the dupuytren's contracture,
but here it is reversible.

Anatomy

A little bit of anatomy.

To the left, we can see the capsule as this wide structure here.

Above the capsule is infraspinatus, and here is what we use the area.

Here is where we place the needle and search inside the capsule when we do injections.

This is to show that the biceps tendon is really an intraarticular structure,
which takes some of the capsule with it on its way down.

This is from an arthroscopic view.

To the left, we have normal joints.

We see the biceps here and here we have a lot of inflammation all around a thick and red capsule.

Here we have an anatomic drawing of the back of the shoulder.

We have the labrum, the glenoid labrum here, the glenoid bone.

Here we have the cartilage and the humeral head from the labrum goes the capsule,
which attaches of course to the labrum.

And it's remarkable how similar this film of the ultrasound shoulder is.

When we have a look at it, we have the triangular labrum with the capsule leaving it
running on top of this black area here, which is not fluid but cartilage.

So the capsule is just right spot on the cartilage.

The lower line here is the humeral head, the bone of the humeral head.

We can run the film and see how it looks in movement.

This is the patient's left arm being laterally rotated.

Clinical Examination of the Shoulder

Then we are going to show the clinical examination of the shoulder.

It's based on the principles of the clinical orthopedic concept, also known as the cyriax concept.

It consists of active movements, passive movements, and isometric movements.

Active Movements

The first movement that we do is active elevation.

We stand in front of the patient and we can go on the backside and look at the scapular movement.

The next movement is the active external rotation, and we look for differences in the range of movement.

We go over to the internal rotation, lift your arms up also here, differences in the range
of movement and we take the active abduction all the way up.

Good.

In a capsulitis or frozen shoulder we will see that it's a decreased range of motion in the affected area
and that is often what we call a capsular pattern.

In the shoulder it consists of decreased range of movement in external rotation, in elevation, abduction,
and at last internal rotation.

Passive Movements

So the first passive movement we're going to do is the external rotation.

It's important to fixate the upper arm.

We go all the way in external rotation and we go all the way to the end and then we'll test the end feel,
which in external rotation is quite soft.

When we have a frozen shoulder or a capsulitis, often the range of movement is quite less.

For example, here we will feel a sharp end feel and the patient will feel often a severe pain in the upper arm.

This pain can last half a minute after the examination.

This is quite typical for the capsulitis.

The next movement that we do is the passive internal rotation.

Take the patient's arm, take it on the back all the way, and if normal we can forcefully do a internal rotation.

If this arm is affected with the frozen shoulder, often the patient will not reach this range of movement.

So it can be only as much as this and it'll be also here severe pain in the shoulder lasting,
as I said earlier, up to 30 seconds.

The next movement we're going to do is the passive abduction, and here it can be useful to fixate the scapula
or fixate the acromion clavicle.

We then hold the scapular apex like this and do the movement.

Normally the scapula rotates within about 90 degrees of abduction.

When we have a capsulitis or a frozen shoulder, it's typically that the scapula rotates within about 30 or 40 degrees.

We can show it here.

We fixate the apex and we can look for scapular rotation earlier or we can fixate here
and we can feel that the range of movement is less here.

In the early stages of capsulitis we can have almost full range of motion, but pain on the end.

Then it can be useful to compare our clinical findings with the ultrasound images.

Isometric Tests

Then we go to the internal rotation isometric test.

Fixate the upper arm and tell the patient to push inwards like this.

It's also here a point that we said about the external rotation that we have the test.

If the range of movement is lesser, we have to test in a resting position like this and push.

At last we do the isometric abduction and here it's important to remember the supraspinatus plane
that goes a little bit more anteriorly.

So we position the arm in a more anterior plane, 20 degrees in abduction, fixate and push outwards.

We look for pain when we do the isometric contractions and after pain.

When we have a capsulitis, it's not so common to have much pain with the isometric tests,
but we can have some referred pain in all movements.

Ultrasound Findings in Frozen Shoulder

So we are going to demonstrate on our patient Lena some of the key features that might be visible
on ultrasound for frozen shoulder.

And the first thing we do is to have a look at the long head of the biceps tendon where there can be observed
a little bit of fluid, extra fluid around the long head of the biceps, which comes from the capsulitis
and the also slight effusion in the joint.

We can actually see a little bit of fluid here around the tendon on the screen here.

The second thing that might be visible on ultrasound is hyperemia in the rotator interval inside the subscapularis,
especially medial to the biceps groove.

This patient used to have that, but now it's less after we have treated her one month ago,
but we can demonstrate it.

We can see it ever so slightly here.

Actually in this screenshot here, we're also going to have a look at the rotator cuff to ensure that we have no particular damage in the cuff.

We have also tested isometric movements clinically of course.

So Lena here has a very nice cuff.

The footprint is clean, the tendon has no clefts, calcifications in the longitudinal and in the transverse plane.

The same, a very nice cuff.

Thirdly, we're going to have a look at the dorsal part of the shoulder to have a look at the glenoid labrum
and the capsule and the humeral head.

For this, we have placed the patient arm in internally rotated position and on the screen here we can see
the first lower curved line, which is the humeral head.

Then the second curved line, which is the actual capsule.

And if we follow the capsule to the right towards the middle of the screen, we can see here it attaches
to the triangle, which is actually the glenoid labrum.

Between the first and second line, we have a dark looking like a space, but there is no space.

It's the cartilage and the second line is very, very close to the cartilage.

There is no actually space in between.

A third line from the bottom is the interface between the infraspinatus and the dorsal part of the deltoid muscle.

And to demonstrate and look for fluid in the joint, we ask the patient to laterally rotate arm while we observe
near the labrum, if we can see any fluid in the joint, which in this case we don't see.

Yes in medial after the injection, we can most of the time see the injectate bulging out during this procedure.

Tips on Performing the Injection

Tips on performing the injection.

We have the patient lying with a painful side up the arm internally rotated.

It's a nice working position and it's nice also to avoid possible fainting.

The therapist stands facing the patient, the ultrasound apparatus on the other side of the patient.

Then the injection is given in plane from lateral to medial and the opening of the needle facing down a little bit more.

We use one milliliter of triamcinolone hex acetonide, which is called ledercort in Norway because it has the longest half time
and lasts a little bit longer in the joint.

The dosage is 20 milligrams per milliliter, dissolved in about eight milliliters of lidocaine 1%.

This relatively large volume gives less percentage miss if misplacing the needle.

The large volume also enables more spread of the injectate, and also you can observe if the needle is filling inside the capsule.

Also, a relatively large volume lidocaine makes it easier to retest to see if the pain is diminishing.

Let's say after five to 10 minutes.

When we do the actual injection, we try to have a picture like we see on the screen now.

We aim with the needle in plane or the probe like this about 30 45 degrees.

And on the screen we see the curvature of the humeral head and we don't have to hit very close to the labrum at all.

Actually, it's easier to hit for the top about 12 o'clock on the humeral head, because that enables better needle visualization.

And we can see on the screen here now in just a minute how the needle is inserted and the injected material reaches its destination under the capsule.

Demonstration of Actual Injection

We're going to demonstrate an actual injection of the joint.

The needle will be coming in from the right aiming towards approximately 12 o'clock.

We can see it sliding just underneath the capsule here.

We see the injected material flow down to the left down towards the labrum.

In that way we are sure that the needle has reached its target.

And here we see a little bit of a miss at the end of the injection also.

But we see in the far left corner how the capsule is bulging out from the fluid.

This is another injection which shows how after first hitting correctly, the needle slips out of the capsule
and make a small bulge on the outside.

Before we go in again, see the needle going through the capsule here.

Looking at the left, we see the injectate some bubbles coming and then we miss you see outside the capsule
and then I don't get the needle back in before or after two tries.

And now the medicine is coming on the correct spot and you see the capsule bulging out.

Model Demonstration of Injection Key Points

We'll make a demonstration of some of the key points regarding the injection itself.

This is a model.

This is the capsule, the glove here on top of the humeral head and the cartilage.

So basically these two things stick together like the glove on this glass.

It's actually no space in between, so we think it's easier to get inside if we put the opening of the needle down.

Some people try to hit down towards the labrum, glenoid labrum.

That makes for a steeper needle angle and it's harder to visualize the needle.

We think it's nice to hit towards like say 12 o'clock like that just to get inside the capsule
and to visualize the needle maximally.

So we make a demonstration if we do the opposite and put the needle opening up, we put the tip inside like that.

But most of the needle opening is on side and this we see the injected material spill outside.

If we turn it around and make a parallel opening to the capsule, the whole of the opening gets inside
and so does the injected material.

We can actually see this on the ultrasound machine.

And it seems to us it's much easier to have a nice entry doing it this way.

That is with the needle opening facing downwards and a needle going in in a fashion like this.

It might also be more safe for the cartilage itself so that the tip doesn't catch the cartilage so easily.

Summary

To summarize, ultrasound guided procedures enables in our view optimized treatment of frozen shoulder
by injection of cortisone and a large volume of lidocaine up to 90% experience markedly or good improvement.

This is also according to GHTA and coworkers from 2009 where they treated 90 patients with very good results
and also our own experience during the last three years treating about 200, 250 patients among the two of us.

In our experience, one to two, sometimes three injections are enough.

Sometimes expect about 24 hours of slight after pain.

Ultrasound guided injections are suitable also for biceps tenosynovitis, rheumatoid arthritis affecting the glenohumeral joint
and osteoarthritis if the symptoms are problematic.

Some research examples, not all of them concerns frozen shoulder, but can be useful note,
especially this one from hashtag SCH and press code.

Acknowledgments

We would very much like to thank reward from Body Examination for excellent work in producing this video and to you.

Thank you for watching.