Advancing Standardization of Ultrasound-Guided Injections in North America

Policy Position Title

Advancing standardization of non-surgical orthopedic interventions in North America.

Position Statement

Healthcare professionals providing in-office interventional pain therapy procedures should be guided by evidence-based practices.

Background

The current landscape in North America estimates 20.4% of Americans experience chronic pain (Dahlhamer et al 2016). With the increasingly aging population and the opioid epidemic claiming the lives of 750,000 people since 1999, healthcare providers must consider alternatives for pain intervention (US Department of Health and Human Services 2010). Office-based landmark-guided corticosteroid injections have been a mainstay in addressing patients’ needs for pain relief. While there is a time and place for the use of injectable corticosteroids, there have been many recent advances in the field of interventional orthopedics, including orthobiologic cell therapy and injectable hyaluronic acid. Interventional orthopedics asserts that responsible interventions include an accurate diagnosis and development of a comprehensive, target-specific treatment plan preceding intervention. Further, clinicians should choose the correct therapeutic agent for the patient and condition being treated and use ultrasound and/or fluoroscopy image guidance to ensure patient safety and efficacy of the injection. The cost of point-of-care ultrasound has decreased dramatically making it affordable for clinicians in private practice. There is overwhelming evidence that image-guided injections are more safe, accurate, and effective than landmark-based injections. The evidence clearly suggests that office-based injections therapies should be image guided and the interventionist should be properly trained using image guidance (Chen et al 2006, Cunnington et al 2010, Daniels et al 2018, Evers et al 2017, Hall and Buchbinder 2004, Koutsianas et al 2016, Naredo et al 2004, Rutten et al 2007, Sibbitt et al 2009, Zingas et al 1998).

Policy Position

Ultrasound or fluoroscopic guidance should be the foundation for practicing competent interventional orthopedics in the evidence-based, case-appropriate delivery of corticosteroids, orthobiologic cell therapy, hyaluronic acid, and prolotherapy.

Recommendations

1. Interventional orthopedic training should be founded in evidence-based established procedures. Each intervention has specific clinical utility and clinicians should be trained in what to use, when, and where, for best outcomes.

2. Ultrasound-guided injections are more accurate, safe, and effective than landmark-guided injections (Korbe et al 2015, Li et al 2019). Diagnostic ultrasound is an invaluable tool to be used with physical exam, special testing, imaging, and thorough patient history (Wang et al 2021). Hence, clinicians performing orthopedic injection therapies should be trained in the use of diagnostic ultrasound and image-guided ultrasound injections.

3. Educating patients about the scope of treatment options, including cost, and providing realistic expectations about treatment outcomes is paramount to the therapeutic relationship.

4. Adjunctive therapies including topical pharmaceuticals (Huang et al 2015), physiotherapy, bracing (Blankstein 2011), and other manual therapies (McLenon and Rogers 2019) should be considered once an accurate diagnosis has been obtained. Adjunctive therapies then can be deployed appropriately. Injection therapy may be the most efficacious advent to treatment based on diagnosis.

5. Clinicians should be trained and equipped to effectively manage sterile/clean procedure protocols and post-procedure care and adverse reactions. Best practices for healthcare providers involve pre-treatment discovery of possible contraindications, full disclosure to patients of risks, benefits, and advantages of proposed treatment, post-procedure follow up visits, and maintaining communication.

6. It is essential that those doing injection therapies have the judgment to know when to refer to a qualified and trained interventional radiologist skilled in musculoskeletal anatomy and pathology or surgeon when indicated.

References

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Chen MJ, Lew HL, Hsu TC, Tsai WC, Lin WC, Tang SF, Lee YC, Hsu RC, Chen CP. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil. 2006 Jan;85(1):31-35.

Cunnington J, Marshall N, Hide G, Bracewell C, Isaacs J, Platt P, Kane D. A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis Rheum. 2010 Jul;62(7):1862-1869.

Dahlhamer J, Lucas J, Zelaya C, Nahin R, Mackey S, DeBar L, Kerns R, Von Korff M, Porter L, Helmick C. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults – United States, 2016. MMWR Morb Mortal Wkly Rep. 2018 Sep 14;67(36):1001-1006.

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Wang C, Zhang Z, Ma Y, Liu X, Zhu Q. Platelet-rich plasma injection vs corticosteroid injection for conservative treatment of rotator cuff lesions: A systematic review and meta-analysis. Medicine (Baltimore). 2021 Feb 19;100(7):e24680.

Zingas C, Failla JM, Van Holsbeeck M. Injection accuracy and clinical relief of de Quervain’s tendinitis. J Hand Surg Am. 1998 Jan;23(1):89-96.