Australian Rheumatology Association
Recommendations from the Australian Rheumatology Association on arthroscopy, ANA testing, imaging, ultrasound and anti-dsDNA antibodies. The ARA supports and educates members and other practitioners in the musculoskeletal field to enable provision of best possible management for patients. It fosters excellence in the diagnosis and management of musculoskeletal and inflammatory conditions through training, professional development, research and advocacy.
Do not use ultrasound guidance to perform injections into the subacromial space as it provides no additional benefit in comparison to landmark-guided injection.
Currently there is no high-quality evidence to support the superiority of ultrasound-guided subacromial injections compared with injections guided by landmarks alone. Based upon moderate quality evidence from five trials, a Cochrane review was unable to find any advantage (in terms of pain, function, range of motion or adverse events) of ultrasound-guided injection over either landmark-guided or intramuscular injection. These results are consistent with a more recent trial. In view of the currently available data and the significant added cost, there is little clinical justification in using ultrasound to guide injections for shoulder pain.
- Bloom JE, Rischin A, Johnston RV, et al. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database System Rev 2012; 8:CD009147.
- Dogu B, Yucel SD, Sag SY, et al. Blind or ultrasound-guided corticosteroid injections and short-term response in subacromial impingement syndrome: a randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012; 91:658-65.
An ARA Evolve working group comprising 19 rheumatologists and 3 advanced rheumatology trainees was established after a call for interest. The group agreed that items should be included if they were either primarily a rheumatologist issue or an issue that rheumatologists should advocate for on behalf of their patients.
A preliminary list of low-value clinical practices was created based upon the working group’s clinical experiences, as well as consideration of potentially relevant items identified from a review of other lists generated. This list was refined into 12 items and small teams for each topic were formed to review the evidence pertaining to these items and their relevance to Australian healthcare.
Brief summaries of the evidence were written based on NHMRC evidence review standards. An anonymous online survey was created based on these summaries and all ordinary (356 rheumatologists) and associate (72 rheumatology trainees) ARA members were invited to participate. Survey participants were asked to select the five recommendations for which they considered the evidence to be the strongest. The survey attracted a 50% response rate and based on its results, the ARA top five recommendations were formulated.
- 1 Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear.
- 2 Do not order antinuclear antibody (ANA) testing without symptoms and/or signs suggestive of a systemic rheumatic disease.
- 3 Do not undertake imaging for low back pain in patients without indications of a serious underlying condition.
- 4 Do not use ultrasound guidance to perform injections into the subacromial space as it provides no additional benefit in comparison to landmark-guided injection.
- 5 Do not order anti-double stranded (ds) DNA antibodies in ANA negative patients unless clinical suspicion of systemic lupus erythematosus (SLE) remains high.