Anterior shoulder pain with radiation into the arm may be secondary to bicipital tendonitis and/or tenosynovitis (22). The biceps tendon can be palpated, but the sheath, if nondistended may offer less than 2 mm clearance to place a needle (22). This is complicated by the caudal extension of the subacromial subdeltoid bursa, which may overlie the bicipital tendon sheath (23). A nonimage-guided injection could therefore result in delivery into an extratendinous synovial space, or possibly result in an intratendinous injection. We have found that ultrasound guidance enables localization of therapeutic agent to the biceps tendon sheath (Figs. 2 and 8).
The patient is placed recumbent with the forearm supinated and the shoulder mildly elevated. The bicipital groove is oriented anteriorly. Using a linear transducer, typically 7.5 MHz, we use a lateral approach with a 22-gauge spinal needle. The long head of the biceps tendon is scanned in short axis. When fluid distends the bicipital tendon sheath, the tip is directed into the fluid. Otherwise the needle is directed along the superficial margin of the
FIGURE 9 Greater trochanteric bursitis. (A) Longitudinal sonogram obtained over the greater trochanter in a patient with pain radiating into the buttocks. A complex bursa (B ) is seen containing nodular hypoechoic soft tissue, contiguous with the greater trochanter (GT ). The patient complained of localized pain with the transducer positioned over this area. (B) Transverse sonogram over the greater trochanteric bursa shows a 22-gauge spinal needle (black arrows) positioned deep into the gluteal muscles (gm) with its tip within the bursa. The appearance of echogenic micro-bubbles (whitearrow) is evident during the injection on real-time observation.
FIGURE 10 Complex ganglion cyst along dorsum of the foot. (A) Longitudinal extended-field-of-view sonogram demonstrates a bilobed cyst in relation to the dorsal capsule of the naviculocuneiform joint. A branch vessel of the dorsalis pedis artery is noted on power Doppler imaging, coursing along the deep surface of the cyst. (B) Using a short-axis approach, a 22-gauge 1.5-inch needle (n) is advanced into the superficial margin of the cyst in order to avoid the deeper arterial branch. The cyst is partially obscured in this image by the strong characteristic reverberation artifact from the needle.
tendon and a test injection of local anesthetic is used to confirm local distension of the sheath, which is then followed by administration of the long-acting corticosteroid. The presence of fluid distension of the sheath with superficially located microbubbles helps to confirm a successful injection.
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