SPORTS MEDICINE

FIGURE 3: BARBOTAGE IN CALCIFIC TENDINOPATHY OF THE SHOULDER

rushing; warn the patient each time of the small risk of infection (approximately 1:1,000-10,000) (14-16)

■ Perform all injections with the patient on the exam couch – there will be the odd vaso-vagal response. It is wise to have up to date immediate life support training and have access to the appropriate resuscitation equipment.

CALCIFICATION

Further detail of individual joint injection techniques is beyond the scope of this article.

lavage with local anaesthetic and aspiration (figure 3). A successful procedure is one where aspiration of calcium is achieved. The bursa is infiltrated with a small dose of steroid post procedure to combat the inflammatory effect of calcium crystals on the bursa (12). In the past this was fluorescien guided (13).

Aseptic techniques vary among clinicians performing injection under ultrasound guidance. As with blind injections, some use gloves, some don’t – though use careful hygiene; some use sterile covers on the probe, but most don’t; some use sterile jelly all the time, others occasionally.

In light of personal experience and observed US-guided injection techniques from several eminent musculoskeletal radiologists, the following general rules normally apply: ■ Change needles between drawing medication (steroid) and injection

■ Change needles between injection anaesthesia and therapeutic injection

■ Use a longer than average needle (ideally 5cm or more) so that the probe and jelly are “away” from the needle entry point

■ Wash hands before/during the procedure ■ Perform the procedure as promptly as is reasonable, without

FIGURE 4: ULTRASOUND-GUIDED INJECTIONS

Most recently interest has also grown in the use of ultrasound guided autologous blood injections (figure 4), often in addition to aggressive needling (or fenestration) of refractory tendinopathic lesions (17-19). Another fairly new technique suggested from Denmark has been to look at the effectiveness of ultrasound-guided electrocautery probe treatment into Achilles tendinopathy, though there are no long term outcomes yet (20). Plantar fasciitis is another condition with a well established track record of US-guided intervention (9, 21, 22) – see figure 5.

Work has also been done on developing the broader concept of ‘sonoscopic surgery’; one example is the ultrasound-guided division of the tarsal tunnel retinaculum (23). The ultrasound probe can also be used to guide needle biopsies, but with the risk of malignancy being uncovered, this is largely, and quite appropriately, the preserve of specialist radiologists. However, whatever the particular interest or skill of the interventional musculoskeletal clinician, in a world where the patient is increasingly keen to know more and more about their treatment and its chances of success, it seems that the use of ultrasound-guided interventions is set to grow.

BIOFEEDBACK MSKUS Though this has until recently been a largely experimental area, interest is growing mainly from physical and manual therapists in the use of MSKUS to augment verbal and tactile instruction on

FIGURE 5: INJECTION OF PLANTAR FASCIITIS

a)

b)

The images above clearly illustrate the precise location of the interventional needle tip with ultrasound guidance in musculoskeletal conditions. On the left, an 18 gauge needle has been guided into the tendon sheath of extensor carpi ulnaris. On the right is a 5cm 14 gauge needle being guided to perform needling and autologous blood injection of a patellar tendinopathy. Whilst both procedures can be performed blindly with palpation and experience, ultrasound guidance proffers further involvement with the patient in their treatment, and gives complete confidence that the needle is correctly located.

www.sportex.net

Here the needle is seen entering from the upper right image, to penetrate and fenestrate the fascia. After this has been done, a depo injection is given at the deep surface of the fascia (not illustrated). An alternate method is artificially depicted by the “yellow needle line”. The angle of the needle is crucial so as to pass through the zone of fasciitis, whilst just missing the front edge of the calcanues where the fascia is attached (yellow dot)

23