All right. Let's go. No disclosures. Objectives will describe techniques to facilitate target and needle visualization, compare and contrast ultrasound guidance versus other methods of injections, and describe the commonly used approaches for shoulder injections. Dr. Tu, it appears that we have your presenter view. I don't know if you're okay with that. It looks great. It's just a little bit smaller. I think everybody likes to see a little bit bigger. There we go. Thank you, sir. And go ahead and continue on. Thank you. All right. So as far as holding the probe, that's the first step. Ultrasound is a contact sport. We are all athletes. Hold it. Don't be afraid to make contact. Hold it at the base. Use your fingers for stabilization. If you don't do that, it's very easy to move the probe and lose sight of either the target structure or the needle. Remember, the beam is the width of a credit card, so you need to be pretty precise. Dr. Sherman talked about ergonomics at the desk. That applies to us as well. Physicians need to take care of themselves. So ideally what you do is you have the patient in between you and the machine. Everything should be at a comfortable distance to reach and to maneuver your arm so that you can reach the patient, you can reach the machine without straining yourself. In case it was not clear, this is the incorrect way to do it. Here's the correct way. So you can see she has everything ready. All her materials for the injection, the syringe, chlorhexidine, gauze, everything is within arm's reach. The machine is not, but let's pretend she has a foot pedal and the patient is in between her and the machine so that she does not have to twist her body or her neck in order to see the screen. So what is wrong with this picture? There's maybe four things. I'll give you all five seconds to think about. Five, four, three, two, one. There's inability to see the screen. There's no stability. This is a small probe. The fingers are not stabilizing. There's no gel, so I don't know what is being transmitted because the machine is also off. So there's, in general, two types of transducers, the linear and the curved. The linear looks pretty, but it doesn't have the best penetration. So it's better for more superficial structures. If you're going to do a deeper joint or, we'll go over later, have a steeper angle for the needle, then you want the curved probe. Just going over some terminology, sliding is moving the probe along the y-axis. Sweeping is moving it along the x-axis. Rotating around the z-axis. Compression, pushing up and down on the probe. That can be helpful if you're assessing for an effusion. Excuse me. You don't want to press too hard because you may compress a vein. Depending what area you're injecting, you may need to be able to see the veins. Like if you're doing maybe a brachial plexus block or something else. Or if you're just trying to find a nerve. Nerves are usually near vascular structures, and if you're compressing them too much, it might make it more difficult to find the nerve. Heel-toe, that's rocking it back and forth along the y-axis. So here you can see, you can use gel to fill in the gap between the probe and the tissue. I don't think this is playing. Oh, there we go. This is my version of heel-toe. Tilting the probe, so that's moving it along the x-axis, just tilting it back and forth. Changing the angle of the probe without actually moving it, at least where it's contacting the body. So all these tools are for visualization of tissue as well as the needle. And remember, pick one type of movement. Don't do two things at once. Just pick one, and pick one direction. It's either right or wrong. So for visualizing the needle, you can do it longitudinally or long axis. The needle would be parallel with the beams, actually perpendicular to the beams of the probe. Actually perpendicular to the beams, but parallel to the probe. This is in-plane, and I like this. This is my preferred way to view the needle because you can see it along its entire length. You can see any tissue that it penetrates on its way to the target. It is more difficult, sorry, it is more difficult to visualize because the beam is thin and the needle is thin. So if you're not stabilizing the probe, you can lose it. The short axis or out-of-plane view, basically you insert the needle perpendicular to the probe. The only thing you can see is a dot. Once you see the dot, you should stop because if you keep inserting or advancing the needle, you're going deeper and deeper, but it still looks like just a dot. We'll go over some techniques later. This is called the standoff oblique technique. So if you're, you know, our bodies are not flat structures, we're curved. So if you have to heel-toe in order to reduce anisotropy, so here you can imagine, say he's injecting the structure here, and just assume that it's in this orientation. The more parallel the probe is to the structure, the better it's visualized. The downside is if you heel-toe it and you're parallel, you lose contact with the body. So you fill in that gap with gel. An advantage to this is not only do you better visualize the tissue, you can go more parallel with the needle. So it's better visualization of the needle and you can visualize the needle before you even penetrate the skin. So what I like to do when I do this is I insert the needle and I sweep the needle, not the probe, I move the needle back and forth until I visualize it directly underneath the probe. And then I can pick my ideal entry point and angle and it makes life very easy. But you have to use sterile gel if you're going to do this. So for the walk-down technique, this is for the out-of-plane method. Again, you only see the needle as a dot. So this is the AC joint. If you insert the needle and you see that it's too superficial to your target location, don't keep advancing it. Stop, withdraw the needle, adjust the angle, either steeper or less steep, and advance again until you see the dot. If you're still not there, just repeat it until you get to where you need to go. I don't prefer the out-of-plane approach because you have no idea what you're hitting on the way to the target structure. So if you're doing the out-of-plane approach, I recommend you scan everything between the target and the needle entry point so you know if it's safe or if there's anything you need to avoid. So needle trajectory, if you start farther away, it's less steep of an angle and you can visualize the needle better. The downside again is that you have to advance the needle through all of this tissue. You have to advance the needle through all of this tissue. Wrong screen for the mouse. So you have to advance the needle through all of this tissue. If you're in-plane, you can start with the probe over here and follow it down. If you're out-of-plane, you should scan beforehand and then go back towards the target. The closer you start to the probe, the sooner you visualize the needle, but then you may have to be very steep, which will decrease the echogenicity. To alleviate this, you have to do the standoff oblique so you can tilt the probe so it's more parallel with the needle and then just squirt some gel to fill in that gap. Alternatively, you can use a curved probe and then the beams are shooting in different directions so that you can better visualize the needle, even if it's quite steep. So for needle advancement, imagine the target is the X and the blue line is the needle. With this approach, if I keep advancing, I'm not going to hit the target. If I try to redirect the needle a bit more superficial, you'll notice the needle will actually bend. So you may notice this when you're doing your trigger point injections. If you're trying to redirect the needle, you might notice this actually bend. So you may notice this when you're doing you might notice it's actually bending. And that's because the needle is within a tissue plane. So what you have to do is straighten out the needle, withdraw it enough so that, so here there's a little pop, you'll feel a pop when you withdraw it, enough so that when you change the angle, it stays straight. And that way, you know, when you advance, it's going in the plane that you want it to. This is showing how the needle beam angle is important for visualization. So the more parallel it is, the better you see the needle. If you start to go steeper, you see less of the needle. So again, to fix this, you have to heel toe the probe a little bit, compress on the distal side, or heel toe and put some gel. If you're having difficulty visualizing the needle, you can jiggle it a little bit, just small movements and look for the most, the deepest area where it's moving. You could do hydrolocation. So I wouldn't do this necessarily with steroid, but maybe with saline or lidocaine or whatever else you're using. Just a quick, not even 0.1 ml, just a little bit and see what it appears like on the screen. And the tip is best visualized if it's bevel up or bevel down. The tip is actually all that matters because if you see the shaft, great, but the tip can be anywhere, right? If you can see the tip and watch it go where you're intending it to, the shaft will not go anywhere else that the tip has not gone. So if you're avoiding blood vessels and anything else with the tip, you can be confident that the shaft will not injure those structures. I'm practicing Michael Scott restraint. Indications for injections. If it hurts, if you're trying to aspirate, debride, or hydrodissect, yada, yada, yada. Tenotoxicity and chondrotoxicity are known adverse effects of anaerobic steroids. Adverse effects of anesthetics. So my anesthetic of choice is ropivacaine because it's the least toxic of these agents. I do not inject lidocaine unless it's for a nerve or diagnostic purposes because ropivacaine is a bit more expensive and it takes a little bit longer to work. Depending on your practice setting, you may or may not have access to it or it may not be economically feasible, but if you are at the VA or in an academic center and you don't care so much about expenses, then ropivacaine is better for the patient. Does the type of steroid you use matter? There aren't very good studies assessing the different steroids. The results vary depending on the studies, but in general it's known that steroid is also toxic, tenotoxic, chondrotoxic. You feel great, but what happens long term? Who knows? So that's why regenerative medicine is such a good option in my opinion. In general, they're very safe, right? What's the worst that happens? It probably hurts a little bit and may or may not work, but even if it doesn't regenerate, it's not going to make the problem any worse. So the different types, there's prolotherapy, usually use an agent like dextrose, platelet-rich plasma, which comes from the patient's own blood. It's spun in a centrifuge and you get the concentrated platelets. bone marrow aspirate obtained usually from the iliac crest, or adipose either from the love handles, or if someone has no love handles and like super lean you may get it from the side of the hip. In general all of these are safe. In general they work. The research is not standardized so there are many different ways to prepare all these. Sometimes people use guidance, sometimes they don't. Sometimes they use an anesthetic that is toxic, sometimes they don't. So if you're looking at studies you have to actually read the details of the study and come to your own conclusion. So why bother with ultrasound? If you can do an injection in two seconds why are you going to take however however many minutes to do an ultrasound injection? I would argue that number one is accuracy. If it were me I would not want toxic material being injected into who knows where. I would like it to be as precise as possible so by far and away ultrasound is much more accurate. I would say even like 86 percent that's for me that's unacceptable because you can see the needle so if the needle is not where you want it to be why would you inject? So some of these studies if you look into it they're not the best but if you can see it it should be 100 percent. As far as efficacy that's mixed sometimes it's more efficacious sometimes it's not but it should not be inferior. So for the subdeltoid injection this is probably the most common one I perform for impingement, bursitis, a tear, for pain relief not for healing unless you're doing regenerative. I like to use the thinnest needles I can. 25 gauge 1.5 inch is my default. 27 gauge usually is too short at least the ones that we have. 4 mls is is more than enough for this for the delta for the bursa and this is my typical mix and I actually may be decreasing this in the future. I may try half an ml of triamcinolone I might start using more normal saline because normal saline is not a placebo. So the subdeltoid injection is more accurate. Efficacy is up for debate. Again it depends what study you look at but this is my technique. I have the patient in the crass position again hand behind the back and that brings the supraspinatus out. You visualize a probe. I rotate it 90 degrees so I'm looking at it in short axis and that way it's an an easy approach. I'm not coming from inferior because then the angle might be a little bit awkward. I'm not coming from medial. I'm coming straight from lateral. I have a lot of room to manipulate the needle or the syringe. It's easy to come parallel to the probe and you can come directly across. If the crass is too painful you can ask the patient to sit on your hand and that they do the the modified crass and you can advance the needle as you inject. So once the needle's here you can start injecting and as long as you see the fluid expanding within the bursa you can either give it all there but I like to keep going so that I see the injectate spread throughout the bursa. For glenohumeral injection indications are arthritis, a large tear for pain relief uh because if there's a large enough tear everything is communicating with each other. So if you do glenohumeral injection it's going to spread to all the areas or frozen shoulder. It doesn't matter how skinny someone is. I 99% of the time use the curve probe. The thickness depends whether or not I'm trying to distend the joint. In frozen shoulder I distend it. Typically I use five mls. I get a good enough spread with that. You can use more if you want. For frozen shoulder there's something called hydrodilatation which is basically actively distending the joint and this is shown to have better improvements with range of motion, better pain relief, but volume and protocols vary. So for example some people may inject 20 mls, some people more than 60. The two special I use a 22 gauge because if I use a 25 and this gets a little bit too difficult to push. I have my typical injectate. So for frozen shoulder I do recommend steroid because there may be that inflammatory component. PRP, not every PRP is the same but I have seen PRP cause frozen shoulder so be mindful of that. And I basically put as much normal saline as I can fit. I'd say nowadays I'm injecting around 40 mls plus the steroid and the ROPE and you can do it with or without a super scapular nerve block for additional pain relief. For glenohumeral, 100% you should use ultrasound. Accuracy is just too unreliable without guidance so use ultrasound please. Or floral, whatever, just use something. My preferred approach, this is a little bit more complicated, is to use ultrasound my preferred approach, there are multiple approaches, but my preferred approach is coming from lateral. So here we can visualize the glenohumeral joint, this is ultrasound, this is MRI. My target is deep to the labrum. So I'm just trying to get the needle nice and secure in there so that when I'm pumping in that fluid I know that it's staying in the joint. If you have an assistant you can use tubing or someone else can help you switch syringes or whatever else, but if you're by yourself you want it secure as possible while you're moving your hands to do other things. Pearls, use the curved probe. If you use the linear probe, remember this is a steep angle, depending how much tissue there is you can go less steep, but you want, if it's steep you want to be able to visualize the probe. And in general the joint is easier to see with a curved probe. I like it bevel up if I'm going deep to the labrum because then I can kind of slide it in there. If I'm just injecting up here then I would do bevel down so I'm not penetrating the cartilage so much. Sometimes you should manipulate the shoulder, meaning internally and externally rotate it. When you do that you can dynamically determine what position will open up the space the most. You just want your life to be as easy as possible so manipulate the shoulder a little bit and as long as it's comfortable for that patient have them maintain that position. And the joint is usually more lateral than you think, so if you're having a hard time finding the joint move the probe more lateral. Suprascapular nerve block, this is good for especially posterior and superior shoulder pain. It's good for arthritis of diffuse pain if there's a big rotator cuff tear. I use it as an adjunct for frozen shoulder. It's an option if nothing else is working. So if someone has failed lenonumeral or subdeltoid, they don't want surgery, suprascapular is safe. It's fairly easy to do. Why not try it? I've had very limited success using dextrose in isolation. I had one patient who had like six months of no pain but just dextrose and lidocaine, and then since then I've had less success, so now I'm back to using more lidocaine and steroid. This is just the anatomy. So the approach, you visualize the suprascapular notch. You should be able to see the transverse scapular ligament coming out over the top. The nerve can be very difficult to see, so what I do is I turn on the doppler and I look for the artery and I go to the opposite side. So if I see the artery here, I'm going to aim for the far end of the notch. If I see the artery here, then I'll aim for the proximal end or the medial end. As long as the tip of the needle is under the ligament, it's going to spread everywhere you need it to. So just get the, if you don't see the nerve, if you don't visualize it, just get the tip under the ligament and away from the artery and it will spread everywhere you need it to. Other things, so this is showing 10x. So 10x is this 16 gauge device. It's basically ultrasound guided tonotomy. So this is the elbow, but whatever. It's got multiple catheters. So with the same device, you can lavage, debride, and aspirate. So all you do is press on a pedal and then you can lavage the area, you can have the needle debride whatever tissue it is you're targeting, and then you can aspirate it all through the same needle. I don't know how, through some wizardry or sorcery, they have calibrated this device so that it apparently does not damage normal tissue. Harry Potter. All right, there's, this is another device. So this is the 10JET device. This is a longer needle than the 10x. The 10x has been known to break. They've made a bigger one. But here's a video of the 10x in action. Oops. Here's this hypo-echoic area is that needle. You can see it basically removes the hypo-echoic tissue and then normal tissue fills in. I guess it just collapses in there. So the data for the shoulder is that this is better for calcific tendinopathy. If you've had a calcific tendinitis patient, it can take a long time to do barbiturates, especially if it's a mature calcification. So prepare, have everything ready. You don't want to stop the procedure in the middle. Protect yourself. Use proper ergonomics. And play. Ultrasound is a contact sport. Get down and dirty. Do whatever you got to do. Don't be afraid. Thank you very much. Great. Thank you so much, Dr. Tu and Dr. Sherman. I know it's hard when you're virtual and you can't really see the audience, but we had a very engaged audience. We had a very engaged audience. They really appreciated your humor and your jokes and all of the visuals. So thank you both. I'll tell my wife that I am funny. Do we have any other questions from here in the audience? Otherwise, I was asked to read, or Dr. Tu, if you want to read, I know you had that question on the chat that you answered in the chat. I can read it here too if the chat is pretty full. So the question was, can you explain the mechanism of how the injection helped indicate a tendon tear, parentheses, when the fluid didn't stay? And was a particular finding or patient complaint that led you to investigating more? If you want to just answer that instead of, or if you want to read what you put in the chat. Yeah. So I'll pull up the picture again. So basically, a lot of slides. So basically, when I was looking at the tendon, I saw the cartilage interface sign, which has a very high, a hundred percent, apparently again, sensitivity specificity for tear. And I saw there was an effusion around the biceps tendon. So these two things for me, alert my spidey senses that there's a tear. So I look extra hard and this is where I assumed it was. So I was treating a patient for a tear. She wanted dextrose. So I, it was like a two for one diagnostic therapeutic. And then when I, when you inject, you can see it. It's the, the injectate is separating that tissue. So the, the layers of the tendon. And when I stop injecting, the tendon is still fairly big. We're only looking at a slice of it. So the fluid is going to spread out. There's communication into the bursa, into the joint. So even though we don't see the fluid here anymore, it's still, it's still there. Great. Thank you very much for that explanation. Any other questions? All right. Thank you so much, Dr. Tu and Dr. Sherman. We really appreciated those, all of the talks this morning. That was great. Thank you. Thank you guys.

ultrasound guidance

shoulder injections

needle visualization

probe handling

glenohumeral nerve block

regenerative medicine

patient outcomes