Pes Bursa Article

[lobelsteve]

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I appreciate Jay Smith's article on US guided pes injections, but it leaves me wondering.....

Is there going to be a clinical difference in close enough to he bursa versus in the bursa?

The data provided for US guided vs blind injections was all for the shoulder. SAB placement is 1.5" to 2" deep in most of my patients, whereas pes placement is always less than 1" deep and usually less than 1/2"deep.

Cadaver studies to show accuracy using US is one thing, but no one cares unless you can demonstrate a clinical difference.

I've never seen pes not get better with PT and a single injection.

 

[RUOkie]

I think you are correct. I also think that US will not be the be all/end all that some of the proponents think it is. I expect that many insurers will start rejecting initial claims for the guidance much like they do for EMG with BoTox.

 

[Phillyborn]

Perhaps its my naivete, but if someone had pes anserinus bursitis, wouldn't the bursa be easier to inject? Kind of like poking an inflated verses uninflated balloon under a bed sheet?

 

[drusso]

As the old saying goes, "There is a good reason for doing something and then the *real* reason for doing something."

The *real* point of the article to generate good evidence supporting the use of US for image guided MSK injections **in general** and thus justify its medical necessity. When it comes time to meta-analyze all the studies of US accuracy, these different studied will be lumped together and "viola" its better to use US for MSK injections than blind...of coursee, some exceptions may apply, but the number monkeys will only look at the overall results.

Just think of how things would be different today if interventionalists did the tedious work of justifying fluoro guidance for facets, etc 20 years ago. The field is trying to learn from its past mistakes. We wouldn't have had FP's, Rheums, etc doing TPI's in their offices and using facet codes if similar articles for facet injection accuracy were done convincing well.

 

[lobelsteve]

So repeat the study with patients and not cadavers. This way accuracy can be measured as well as outcomes.

 

[PMR 4 MSK]

And with a swollen/inflamed bursa, due you really want to increase the pressure within it by putting more fluid in it? Maybe that is why some people complain about bursa injections so much and others feel little. Maybe not.

 

[dc2md]

So repeat the study with patients and not cadavers. This way accuracy can be measured as well as outcomes.

What the guys at Mayo did was inject colored latex into the bursa. Don't think too many patients will volunteer for that. Contrast might be okay, but definitely not as good.

Another thing they did in this study is, because these were cadaver legs without functional ability to say "ouch", they used the ultrasound to locate the center of the bursa in each group. SO, would the unguided group be even less accurate in real patients?

How about a study looking at the accuracy of finding the center of the bursa with US-guidance vs the "ouch" (point of maximal tenderness) method?? I'd like to see that.

But you're right, the most important thing would be a study with clinical effectiveness between US-guided vs unguided pes anserine bursa injections (same steroid, same volume).