Ultrasound-Guided Shoulder Injection or Ultrasound Guides the Shoulder Injection?: Standard Versus State-of-the-Art

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To the Editor:
We have taken interest in the recently published article entitled “Point-of-care ultrasonography findings and care use among patients undergoing ultrasound-guided shoulder injections” by Lee et al.1 In this era of ultrasound (US) use in physiatry,2 we congratulate the authors for this comprehensive study where they have discussed their data on diagnostic and interventional shoulder US. Herewith, we would like to draw attention to a few issues with regard to the liberal but prompt use of US for interventional physiatry.3 First, the authors mention that in case of discrepancy between the clinical and ultrasonographic findings, the decision pertaining to the injection was based on the clinical diagnosis. Keeping in mind the concept of diagnostic US (i.e., “seeing is believing”),4 we need to oppose to this. For instance, if one patient is suspected to have subdeltoid/subacromial bursitis, but after thorough (static and dynamic) imaging, one fails to prove it; the decision to proceed in favor of a bursal intervention (drainage or injection) would be quite skeptic.5 Second, concerning the technique of glenohumeral injection, the authors have depicted a lateromedial approach from the posterior side. In that case, one should be very cautious not to injure the labrum (on the needle trajectory) while reaching the joint space. Herein, we need to also remind that lateromedial approach would be much safer. Last but not the least, reminding of the concept of interventional US (i.e., approaching from wherever we have the optimal access, “liberating physical and rehabilitation medicine”),6 it is noteworthy that the diagnostic US findings might definitely change/modify the technique of intervention.3 For example, to have an eventual intraarticular access,7 the needle can preferably/readily be placed in the bursa (in case of a full-thickness rotator cuff rupture) or in the proximal bicipital sheath (in case of fluid presence around the biceps tendon anteriorly) as well.

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