guided interventions in musculoskeletal ultrasound

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Review

Guided interventions in musculoskeletal ultrasound:whats the evidence?

J. Davidson*, S. Jayaraman

St Richards Hospital, Spitalfield Lane, Chichester, West Sussex, UK

a r t i c l e i n f o r m a t i o n

Article history:

Received 2 March 2010

Received in revised form

13 August 2010

Accepted 21 September 2010

Increasing histological and radiological understanding of the processes involved in soft-tissue

injury is leading to novel targeted treatments. A number of reviews have recommended that

these treatments should be performed with image guidance. This review describes current

ultrasound-guided interventions and injections, together with the level of evidence for these.

Discussion of guided interventions will include; percutaneous lavage (barbotage), brisement,

dry needling, electrocoagulation, and of guided injections; corticosteroids, autologous

substances (blood and platelet rich plasma), sclerosants, and prolotherapy (hyperosmolar

dextrose). Representative imaging illustrating some of these techniques is included for

correlation with the methods described. As these procedures are often performed in sports-

people, it is essential that the radiologist is aware of prohibited substances and methods

outlined in an annual publication from the World Anti-Doping Association (WADA). Finally,

future directions, including the use of autologous substances, mesenchymal and stem cells will

be discussed.

2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction

Ultrasound is essential in soft-tissue injury diagnosis andtreatment, including tendon, muscle, and nerve patholo-gies. Ultrasound-guided interventions straddle conserva-

tive and surgical management and improve patientsquality of life in those unsuitable for surgery.

Ultrasound-guided procedures allow assessment of

lesions and evaluation of procedure tolerance. Radiologistsmust remember that they are clinicians and hone theircommunication skills to improve the patient experience.

Ultrasoundallows real-timeaccurateplacement of treatment.Recent government initiatives to increase physical

activity will probably increase activity-related injury. There

is an increasing body of evidence from non-radiologyspecialties performing these techniques, both blind and alsounder ultrasound-guidance. Radiologists must lead evalu-

ation of these techniques to ensure they are evidence-basedand performed safely.

Informed consent is essential, assisted by the referring

clinician explaining the procedure in clinic. We routinelysend an information leaflet with the appointment letter.

Patients can generally perform activities of daily living butshould refrain from strenuous exercise for 72 h. Anaphy-laxis is rare but should be considered. A high frequency(7e12 Hz) linear probe should be used.

There is surprisingly little evidence in the literatureregarding the efficacy of the methods used for infection

prophylaxis.1 Our practice is to clean the puncture site with

an alcohol solution. The probe is cleaned and sterile salineused as a coupling agent. Our audited injection rates arezero in over 2000 injections with this technique. Readers

should be aware that using alcohol directly on the probe

* Guarantor and correspondent: J. Davidson, 34 The Avenue, South-

ampton, Hampshire SO17 1XN, UK. Tel.: 44 7894 076 939.

E-mail address: [email protected] (J. Davidson).

Contents lists available at ScienceDirect

Clinical Radiology

j o u r n a l h o m e p a g e : w w w . e l s e v i e r h e a l t h . c o m / j o u r n a l s / c r a d

0009-9260/$ e see front matter 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.crad.2010.09.006

Clinical Radiology 66 (2011) 140e152
mailto:[email protected]://www.sciencedirect.com/science/journal/00099260http://www.elsevierhealth.com/journals/cradhttp://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://www.elsevierhealth.com/journals/cradhttp://www.sciencedirect.com/science/journal/00099260mailto:[email protected]


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may invalidate the warranty. Full draping and probe coversis reserved for deep injections.

This is an extensive topic; therefore, biopsy, joint aspi-

ration, and foreign body removal have not been included.The studies cited refer to adult patients only. Almostexclusively published papers have been referenced.

We will describe these techniques and the evidence for

guided interventions and injections of therapeuticsubstances. Table 1 lists the included techniques, Table 2

summarizes the current evidence, Table 3 lists thekey studies and Table 4 lists information pertaining toregulations of the World Anti-Doping Association

(WADA),52 which governs the use of prohibited substances

and methods of administration in many sporting bodies.

Guided interventions

Dry needling

This technique involves needle insertion into the lesionsite, then repeated puncture aiming to stimulate aninflammatory healing response (Fig. 1). Disruption of

collagen fibres at the lesion causes local haemorrhage. Thehypothesis is that inflammation leads to granulation tissueformation and tendon strength.2 Indications include:

patellar tendinosis,2 lateral epicondylitis,3 medial epi-condylitis,4 and plantar fasciitis.5 There is anecdotalevidence in Achilles tendinosis and adductor insertion

tendinopathy.To our knowledge, there are no studies in the literature

that purely use dry needling, although studies exist that

combine dry needling with autologous blood injection.2e4

Further work is needed.

Brisement/percutaneous hydrostatic decompression

This has been described under different terms, includingbrisement and high-volume image-guided injections. It is

suitable for use in Achilles tendinopathy as there is notendon sheath, surrounded by connective tissue, the para-

tenon. The development of abnormally oriented vessels andnerves, is felt to contribute to pain.6,7 Therefore, a physicalmethod of disrupting these neurovascular structures is

thought to reduce pain. Surgical management of Achillestendinopathy includes: open or percutaneous tenotomy,peritenon and tendon debridement.7

The review by Cormick8 describes a method using 20 mlof cold 0.9% saline with celestone (betamethasone) andlocal anaesthetic, which is injected to strip the paratenon off

the tendon. No prospective results are available with regard

to short- or long-term pain relief. The use of steroids, in thecontext of abnormal tendon, is not advised because of thepotential risk of rupture from inadvertent intratendinous

injection.9

However, peritendinous steroid injections have not beenshown to be associated with an increased risk of rupture.10 In

a retrospective study of 64 patients, one group was givenblind peritendinous or intrabursal injections of 1 ml hydro-cortisone and 1 ml 1% xylocaine with light training. The

second group underwent physical therapies only. Follow-upwas performed over 1 year. Two ruptures occurred in eachgroup; however, the image-guided injections gaveimproved

results. A further small study of 28 patients 11 divided into

twogroups, involved the blind peritendinous administrationof either bupivacaine and prednisolone or bupivacaine

alone. No tendon ruptures occurred. However, there wasonly a 33% incidence of complete pain relief.

A study by Chan et al. (2008),12 a prospective study of 30

patients, with refractory Achilles tendinopathy, underwentan injection of 10 ml 0.5% bupivacaine, 25 mg hydrocorti-sone and 410 ml normal saline, to between the anterior

aspect of the Achilles tendon and Kagers fat pad. Vascu-larity was assessed with power Doppler and eccentricloading was prescribed. The results from visual analogue

scores (VAS), showed a significant improvement in pain inthe short term (2 weeks), with a mean change of 50 mm,

from a mean of 76 mm to a mean of 25 mm (asymptomaticpatients should score a VAS of 0 mm). There was alsoa statistically significant improvement in function with

a mean gain of 50 mm. The VISA-A (Victorian Institute ofSport Assessment-Achilles tendon)13 scores, reflectingsymptom extent, showed a significant reduction after 30weeks, with a mean VISA-A score pre-procedure of 44.8

points and 76.2 points post-procedure (an asymptomaticpatient scores 100 points).

In our institution, this technique is used in refractorymid-Achilles tendinosis.14 After clinical and sonographicassessment of the symptomatic Achilles, ultrasound guidesthe needle between the paratenon and the abnormal

tendon. Up to 7.5 ml of 0.5% bupivacaine is then injected intothe site over three sessions with the aim of expanding this

space (Fig. 2). It is important to combine any interventionswith eccentric loading between sessions, as a systematicreview of nine studies by Kingma et al.15 demonstrated a 60%mean pain reduction in the eccentric overloading groups

compared to 33% reduction in the control groups.

Electrocoagulation

This technique treats painful chronic Achilles tendinop-athy. Neovessels and nociceptive fibre formation are

hypothesized to cause pain. This was substantiated by

Table 1The different ultrasound guided procedures and their mechanisms of action

Category Technique Mechanism

Guided Interventions Percutaneous lavage Calcium fragmentation

Dry needling Tendon repair

Brisement Neurolysis

Electrocoagulation Neurolysis

Cryotherapy Neurolysis

Injectable substances Local anaesthetics Diagnostic/analgesic

Corticoster oids Anti-inflammatory

Autologous substances Tendon repair

Sclerosants Neurolysis

Prolotherapy Tendon repair

Botulinum toxin A Muscle relaxation

Future directions Mesenchymal stem cells Tendon repair

J. Davidson, S. Jayaraman / Clinical Radiology 66 (2011) 140e152 141


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sclerosant therapy,16 where reduction in neovascularity,

correlated with reduction in pain.Specialized equipment is required. A pilot study by Ilum

Boesen et al (2006)6 used a unipolar 16 G coagulation needle

connected to an ICC 80 electrosurgical Workstation forMinor Procedures (ERBE). This requirement may limit

availability. The pilot study by Ilum Boesens group6

employed 11 patients in a prospective study, all of whichhad been diagnosed with chronic Achilles tendinopathy. The

coagulation wattage was set at 20e25 W and operated viaa foot pedal. The procedure was performed under asepsiswith local anaesthetic cover. Using ultrasound guidance, the

needle was positioned against vessels entering the Achilles,equating to the position used in sclerosant therapy. Doppleridentified neovessels initially and also response to treat-

ment. Ice compression was used to reduce reactive hyper-aemia. Gentle exercise was permitted.

The Likert box scale (0 to 10) pain score was employed.All patients were given at least one treatment, with furthertreatment offered if symptoms persisted with intra-

tendinous hyperaemia. After 6 months, the mean pain score

reduction was 7 (activity) and 1 (rest). At 6 months, therewas no change in vascularity or size of tendon. Postulated

complications included infection at the insertion site, nervedamage to the sural nerve, and tendon rupture.6 Electro-

coagulation is an emerging technique that may havepotential in the treatment of chronic tendinopathy.

Cryotherapy

Data on percutaneous cryotherapy for painful neuromataare beginning to become available.17 This technique hasbeen applied to treat trigeminal neuralgia18 and renal

tumours.19 Superficial cryotherapy has been used in phys-ical therapy and anaesthetics.

In a letter to the American Journal of Roentgenology,

Neumann and OConnor,17 describe a pilot study of 10patients who presented with refractory stump neuromapain. The cryoprobe was positioned according to electro-

physiological parameters. The endpoint of the treatmentwas either cessation of local tenderness or completion offi

ve freezee

thaw cycles. There was a good response of 90%

Table 2

This table contains an evidence statement for each procedure based on the available published literature. The evidence levels are taken from the Centre for

Evidence Based Medicine77

Evidence

Level

Guided

Interventions

Dry Needling There is anecodotal evidence only for its use in tendinosis of the Achilles, patellar, triceps

and adductor tendons. No randomised controlled studies have been performed formally

as yet.

5

Brisement Single prospective, non-randomized study of 30 patients with Achilles tendinosis using

local anaesthetic and injectable steroid demonstrated significant pain and function

reduction over 30 weeks. Further work is needed.

2

Electrocoagulation Singleprospective, non-randomizedstudyof 11 patients,which showedsymptomaticrelief

following electrocoagulation of neovessels of the Achilles tendon. Further studies are

required at different sites and with control groups.

2

Cryotherapy Currently, there are no randomized, controlled studies for cryoablation under ultrasound-

guidance. As, there is only one case study for ultrasound-guided cryoablation of the

genitofemoral nerve, there is no evidence base as yet.

4

Percutaneous lavage There is strong evidence and understanding of the pathophysiology, in the clinical scenario

of calcific tendonitis of the rotator cuff, in particular, the supraspinatus tendon.

2

Injectable

substances

Corticosteroids There are a number of Cochrane systematic reviews assessing the evidence for use in

shoulder pain, de Quervains tenosynovitis and trigger finger. Retrospective studies have

shown medium-term benefit in interdigital neuroma, de Quervains, and subacute

posteromedial ankle impingement

1

Autologous substances There are a number of conflicting factors in the current studies of autologous blood andplatelet-rich plasma (PRP), including combination with dry needling. Follow-up periods

have also been relatively short. Further research is needed with comparative therapies and

control groups.

2

Sclerosants Studies show that ultrasound guided sclerosant injection produce successful results in

stump neuromata, Achilles tendinosis, and patellar tendinopathy. Studies that involve

crossover treatments are difficult to evaluate.

2

Prolotherapy Small studies performed in Achilles tendinosis and plantar fasciitis have shown reductions

in pain. Randomized, controlled studies are required.

2

Botulinum Toxin A There are several randomized, controlled studies for use of botulinum toxin type A in

iliopsoas spasticity and lateral epicondylitis, which demonstrated medium-term muscle

relaxation effects. Further non-ultrasound guided studies on plantar fasciitis have also been

published.

1

Future

directions

Tenocyte-like cells There is a single study using laboratory prepared cells for treatment of lateral epicondyitis,

which demonstrated reduction in pain and functional disability.

4

Level 1 includes high quality randomized controlled trials and systematic reviews.Level 2 includes prospective comparative studies.

Level 3 includes case-control studies, retrospective comparative studies.

Level 4 includes case series.

Level 5 includes expert opinion.

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pain relief 3 months after treatment, but at 1 year, only

three patients had continued pain relief. The authorssuggest that cryotherapy combined with high-resolutionsonography may be useful. The benefit of cryotherapy over

phenol is reduced risk of local tissue necrosis.There is a single case report20 of ultrasound-guidedcryoablation of the genitofemoral nerve for inguinal pain.

The cryoablation treatment was preceded by a diagnosticinjection of local anaesthetic, which provided immediatepain relief. Two 3 min intervals of treatment were given via

the cryoprobe, under direct visualization. The patientremained pain-free at 2 months with no recorded post-

procedure complications. These initial publications indicatethat ultrasound-guided cryotherapy for painful neuromatamay be of benefit but further trials are needed.

Percutaneous lavage

Percutaneous lavage is synonymous with barbotage orimage-guided needle irrigation and aspiration. It isdescribed in a number of review articles21 and can involve

either a one or two needle approach to break up intra-tendinous calcifications.21

Barbotage was first described three decades ago as

a fluoroscopic procedure by Comfort and Arafiles (1978).22

The earliest description of an ultrasound-guided tech-nique was by Farin et al.,23 which was a case series of two

patients who underwent needle puncture (with an 18 Gneedle) of their supraspinatus tendons and alternateinjection of saline and aspiration of calcium apatite crystals.

A new technique has been described which involves

a fine-needle technique (22 G) with lavage of 1% lignocaine,which has led to reduced pain and disability, in a prospec-

tive study of 30 patients.24 The measure of pain and func-

tion was by the Shoulder Pain and Disability Index (SPADI)questionnaire, using visual analogue scales. Patients atten-ded a follow-up appointment at a mean of 53 days, where

the overall SPADI decreased by 27%, with pain reduced by30.5% and disability by 23.9%.

At our hospital, a two-needle technique is performedwhereby saline solution is injected through one needle anddissolved calcium extracted through the other. Serafini

et al.74 have shown improved symptoms at 1 and 3 months

and 1 year using this technique.Other therapies used for calcific tendinopathy include

(external) ultrasound therapy,25 extracorporeal shock wave

therapy,26 active non-operative treatment,27 and open or

arthropscopic subacromial decompression.

27

Injectable substances

There are a variety of therapeutic agents available. Imageguidance is essential and awareness of side effects.

Local anaesthetics

Local anaesthetics provide immediate pain relief andassist in diagnosis. However, significant adverse effects tothe central nervous and cardiovascular systems can occur

Figure 1 Dry needling. (a) Shows a thickened hypoechoic are on the inferior aspect of the patellar tendon (arrowed) with some increased

vascularity. (b) Shows the position of the needle within the area of tendinosis during the process of dry needling.

Table 4

This table summarises the WADA regulations, which relate to musculoskeletal radiology procedures. The annual publication divides these into prohibited

substances and methods

Regulation When prohibited

Substances

S2. Platelet-derived preparations

Prohibited if administered intramuscularly. For administration via other routes, a declaration of use is

required in accordance with the International Standard for Therapeutic Use Exemptions)

At all times (in and out of competition)

S9. Glucocorticosteroids

All are prohibited when given by oral, intravenous, intramuscular or rectal routes. Declaration of use must

be completed by the Athlete for administration via intra-articular, peri-articular, peritendinous, epidural,

intradermal and inhalational routes.

In competition only

Methods

M1. Enhancement of oxygen transfer

Blood doping, including autologous, homologous, heterologous blood or red blood cell products

At all times



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with inadvertent intravascular injection.28 Local adverseeffects include chrondrolysis,29 particularly if administeredwith vasoconstrictors.28 Although not used currently in our

hospital, 0.5% ropivacaine (Naropin) has been shown to beless toxic to human articular chondrocytes in vitro

compared with 0.5% bupivacaine.30

Indications include joints,31 bursal,31 peritendinous11

lesions, and interdigital neuromata.32 They are often injec-

ted simultaneously with corticosteroids to provide painrelief. Local anaesthetics block sodium-specific ion channelson neuronal cell membranes, inhibiting signal conduction,

with smaller neurones inhibited first.There are two main groups: esters (cocaine and

procaine) and amides (lignocaine, bupivacaine). Severe

allergic reaction is more common with esters. Action ispotentiated by the vasoconstrictor action of adrenaline,

which decreases vascular absorption.The most commonly used preparations in the UK

include: procaine hydrochloride (Novocain); lignocaine

hydrochloride (Xylocaine); and bupivacaine hydrochloride(Marcaine).

Procaine has the shortest duration (30e60 min), ligno-

caine moderate (80e120 min) and bupivacaine the longest(180e360 min).28 Bupivacaine is used most frequently forradiological musculoskeletal procedures. A contraindication

is previous allergic reaction to amide anaesthetics. Local

sepsis is considered a relative contraindication due to therisk of introducing infection into the joint. The maximum

safe dose of bupivacaine is 2 mg/kg. However, there hasbeen recent concern over the toxic effect on chrondrocytesby bupivacaine.29 Injection of corticosteroid concurrently

may ameliorate this effect.28

Corticosteroids

Corticosteroid injections are a widely used therapy (blindand ultrasound-guided) for their anti-inflammatory prop-

erties and to provide medium-term symptomatic relief.Where ultrasound guidance is employed, indicationsinclude joints, bursae, tendon sheath, interdigital

neuromas, and spinal indications (usually under fluoro-scopic guidance).28 A reference text, such as McNally Prac-tical Musculoskeletal Ultrasound,33 should be consulted for

details of patient positioning.Several studies34,35 have demonstrated that image-

guided steroid injections of the shoulder and knee produce

improved results over blind injections. Accurate placementis associated with improved clinical response. A prospectivestudy by Eustace et al. (1997)34 with 37 patients in 38

shoulders, and using iohexol as a guide to accuracy of blindsteroid placement, demonstrated a 37% success rate in

injection placement.

Figure 2 Brisement: a, b and c demonstrate the process of brisement for treatment of Achilles tendinosis and paratenonitis. (a) Shows

a thickened, asymmetric Achilles tendon in transverse section, with hypoechoic areas. (b) Shows the position of the needle (black arrow)

between the paratenon and the tendon, with a crescent of hypoechoic saline and local anaesthetic (white arrow). (c) Illustrates the resulting

space (black arrows), which correlates with reduction in symptoms at six weeks.



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These synthetic corticosteroids are prednisolone-derived: methyl prednisolone acetate (Depo-Medrol,Medralone); triamcinolone acetonide (Kenalog); betame-

thasone acetate/sodium phosphate (Celestone soluspan,Betaject); dexamethasone sodium phosphate (Decadronphosphate, Adrenocot, Decaject); and hydrocortisone.

There is a low complication rate: joint infection

(


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Edwards and Calandruccio49 also performed a small

study of 28 patients, where 22 responded to autologousblood injections, with a reduction in the Nirschl score.However, these injections were given blind and mixed with

local anaesthetic. To optimize the treatment, we feel thatimage guidance should be used. A further small study of 27patients treated with autologous blood for medial epi-

condylitis4 also showed an improvement in the VAS scorespre and post-procedure. However, dry needling was againperformed with no control group.

Animal studies have been performed using of PRP inrabbit and horse tendon disease. A small number of humanstudies are available in the general medical literature. The

benefit of PRP over autologous blood is that the concen-tration of platelets is four to five times higher. The growth

factors (GF) contained in the a granules of the platelets

become activated at the site of injury and continue to act forthe next 7 days. It has been suggested that for this reason,

a repeat injection should not be required.

48

There arefew studies in humans with PRP. Sanchez et al.50

reported a case series of 12 athletes, half of whom under-

went open suture repair following complete Achilles tendonrupture, and the other half underwent the same operation

butwiththeadditionofaPRPinjectiontothewoundedends.In the second group, there was an earlier return to normalrange of motion, with no wound complications.

A larger cohort study of 20 patients with mostly refrac-tory lateral epicondylitis was performed, where five

patients were controls and injected with bupivacaine, andthe remaining 15 were given a single percutaneousinjection of PRP.45 Injections were made at the site ofmaximal tenderness. Four weeks post-procedure, the PRP

treated patients reported a mean 46% improvement withthe control group reporting a 20% improvement. ThePRP treated patients continued to have pain relief at 8

weeks and 6 months.ACS is derived from incubating the blood with glass

beads and spinning the blood down in order to extract the

Figure 3 Autologous blood. These images show injection of an autologous blood patch in the repair of a partial tear of extensor carpi radialis

brevis (ECRB). (a) Shows an anechoic area in the ERCB (white arrow) with associated hypervascularity secondary to neovascularity (black arrow).

(b) Illustrates the injection of autologous blood (white arrow) to the site of tear (needle arrowed black). (c) Two months later, the neovascularity

has decreased (black arrow) and there has been regeneration of tissue at the site of partial tear (white arrow).



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serum, which contains the released GF. However, thismethod is less popular than producing PRP, as it producesa lower yield of GF.51

A number of potential risks have been postulated forautologous substances.51 Potential local complicationsinclude the induction of excessive fibrosis, due to the

presence of TGF-b1 or by concomitant use of non-steroidal

anti-inflammatory drugs (NSAIDs). Potential systemic risksinclude; infection (although this is unlikely with autologoussubstances) and effect on the serum GF levels (which have

been shown to decrease in some small studies 52).The caveat in treating sports people is in the WADA

prohibited list,53 which is published annually and includes

both prohibited methods as well as prohibited substances.Section S2 states that it is prohibited to administer growthfactors, including platelet-derived preparations, by an

intramuscular route. Other routes of administration wouldrequire a declaration of use. In the context of enhancementof oxygen transfer (section M1), blood doping, which

includes the use of autologous blood products, is prohibited

(see Table 4).The scientific and clinical basis for the use of autologous

substances continues to develop in the musculoskeletalfield. More research is needed to integrate ultrasound-

guided administration of these substances.

Sclerosants, phenol/polidocanol

These are indicated in patellar tendinosis,54 tenniselbow,55 chronic Achilles tendinosis,16 Mortons56 and

stump57 neuromata; the outcomes for which have beenassessed in small pilot studies.

The most common sclerosants used are phenol or poli-docanol. Phenol is used for alcoholization of interdigitalneuritis via a percutaneous intraneural route and causes

a chemical neurolysis (due to its affinity for nerve tissue),causing dehydration and necrosis.58 Polidocanol is a localanaesthetic agent, which is a licensed drug and used for

sclerosis of varicose veins and telangiectasia.16 The

proposed hypothesis for its beneficial effects in chronicAchilles tendinosis is that the developmental of neo-

vascularity around the abnormal tendon is associated withabnormal nerve growth at the same site15 and pain. Thetheory is that sclerosis of these neovessels reduces pain.

However, it is still unproven whether neovascularity isbeneficial or detrimental.

A pilot study comprising 10 patients16 demonstrated 80%

satisfaction. During activity, there was reduced pain with noremaining neovascularity after an average of two injections.In the two patients that had ongoing pain, neovascularity

remained. The thickness and structure of the Achilles wasunchanged and no side effects were identified. Limitationsof this study included small sample size, lack of control

group and patients not blinded to the treatment.A prospective study by Magnan et al.56 involved 71

patients who were treated via a dorsal approach to the

intermetatarsal space. They used a needle electrode con-nected to an electrostimulator to accurately locate the nerve

by reproduction of paraesthesia to the digits. At this point,

2.5 ml phenol in 5% solution with water was injected fol-lowed by local anaesthetic for analgesia. Pain relief wasassessed by VAS with treatment proving effective in 80%. No

complications occurred over a mean of 36 months.Gruber et al.57 described a prospective study of 82

patients who they treated with sonographically-guided

injection of up to 0.8 ml of 80% phenol for stump neuro-

mata. Pain was assessed by VAS. Twelve patients werepain-free after one to three treatments. Nine of these werepain-free after the first treatment. At 6 months, 52 patients

had reduced pain of varying degrees. Minor complicationswere identified in 5% of the total treatments given: non-specific painful soft-tissue oedema, painful local myopathy,

confined infection, and local soft-tissue necrosis.Two treatments for lateral elbow tendinosis were

compared in a prospective, randomised, controlled, double-blind study of 32 patients.55 In this study, the patients weredivided in two groups, one treated with polidocanol,the other with lignocaine and adrenaline. At 3 months, the

lignocaine group were offered crossover treatment of

polidocanol. Outcomes were assessed by patient satisfac-tion with treatment, VAS during activity, and maximal

voluntary grip strength. No difference between the twogroups was seen, both had significantly reduced VAS at 3

and 12 months, with a significantly higher grip strength at12 months. The overall success rate was 50e62%.

These studies show promising results for the use of

sclerosants in Mortons neuroma and painful tendinopathy.

Prolotherapy

Prolotherapy (also known as regenerative injectiontherapy) is a technique where a small volume of an irritant

substance is injected around a ligament or tendon inser-tion59 to initiate a local inflammatory response. The mostcommonly used irritant is hyperosmolar dextrose, which

has been trialled for the treatment of osteoarthritis of theknee, lower back pain, sacroiliac dysfunction,60,61 and

lateral epicondylitis.60 More recently, prolotherapy has

been combined with ultrasound guidance in Achilles ten-dinosis59 and plantar fasciitis.62 Hyperosmolar dextrose is

thought to work by osmotic rupture of cells. Other irritantsinclude phenol glycerine glucose (P2 G), which causes localcellular irritation and sodium morrhuate by chemo-attrac-

tion of inflammatory mediators.21

In a prospective study59 of 33 tendons, 32 patientsunderwent a mean number of four sessions of 25% dextrose

injection at 6 weekly intervals. VAS assessments and tendonsize were measured before and during the treatment. Therewere significant reductions in pain (from 38 pre-treatment

to 4.5 after, 88.2% difference), with minimal change intendon size (11.7 to 11.1 mm thickness). No complicationswere identified in this group. However, limitations include

lack of control group and absence of blinding.A further study21 examined the use of hyperosmolar

dextrose for treatment of refractory plantar fasciitis in

20 patients. Ultrasound-guided intraligamentous 25%dextrose/lignocaine solution was administered at 6 week

intervals for a median of three treatments. Overall, 80% had



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a good to excellent outcome. Again, no control group wasused and the patients were not blinded to the treatment.However, if further studies show that this technique is

beneficial, then there is a clear advantage over steroids,which have a risk of rupture of fascial bands.

Further small studies have been published using blind

injections of dextrose and lignocaine for chronic groin

pain63 and coccydynia64 showing promising results, butfurther studies with ultrasound guidance are awaited.

Botulinum toxin type A

This substance is relatively new in the musculoskeletalfield, with key indications being for muscle spasticity

(iliopsoas, gastrocnemius),65 lateral epicondylitis,66,67

plantar fasciitis,68 and in the chronic pain setting.However, in rehabilitation units botulinum toxin is often

injected blind. Several studies have emerged demonstratingincreased accuracy of placement with sonographic guid-ance.69,65 In addition, a randomized study68 of 43 feet with

refractory plantar fasciitis, using patients with bilateralsymptoms, demonstrated significant improvement in thefoot injected with 50 units of botulinum toxin type A in 1 ml

of normal saline. The amount of toxin varies, with somestudies using up to 120 units.65 For treatment of the plantarfascia,68 a needle is inserted into the fascia via a posterior

approach below the calcaneus. For treatment of iliopsoasspasticity,65 the injection is made via an anterior approach,into the pre-insertional segment of the distal iliopsoas,

proximal to the myotendinous junction and beneath theinguinal ligament. In our institution ultrasound-guidedbotulinum toxin injections are used with good effect in

stroke patients with muscle contractures.

Future directions

Key areas that are anticipated to receive more attention

over the next few years include the use of growth factors,51

mesenchymal stem cells,68,70,71 and skin-derived tenocyte-like cells72 for the treatment of tendinopathy and muscle

injury. Aprotinin (serine protease inhibitor) peritendinousinjections may reduce collagen degradation in tendinop-athy, as shown in studies on patellar and Achilles tendin-

opathy without positive results.73 In the field of sportsmedicine, Traumeel (a homeopathic medicine) is widelyused as an ointment, gel, droplets, tablets, and injectable

solution. No randomized controlled trials regarding itsefficacy have been published.

Conclusions

This paper outlines the numerous options for ultra-sound-guided therapies currently being explored in the

field of musculoskeletal radiology. We have tried to assessthe available literature and identify the current evidence-base for the different treatments. However, it is important

to recognize that there is a bias towards publishing positiveresults. It is important to raise awareness in clinical

colleagues about these minimally invasive, percutaneousoptions, especially, in the context of patients who are notsurgical candidates and those patients with refractory

symptoms after standard conservative management. All ofthese treatments, however, should be taken in the contextof other non-radiological treatment options such as phys-

iotherapy, podiatry, and orthotics, and it should be borne in

mind that if the radiological treatment fails, surgicalmanagement might be required.

Acknowledgements

The authors thank Dr N. Kendall for her contribution.

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