Nimish Mittal

Background: Ultrasound-guided intra-articular injection of the shoulder via the rotator cuff interval (RCI) is increasingly used for adhesive capsulitis, but conventional techniques may be technically demanding and potentially risk iatrogenic rotator cuff tendon injury. Objective: To describe and validate, in cadaveric specimens, a novel long-axis RCI injection technique aligned with the intra-articular portion of the long head of the biceps tendon. Methods: Six shoulders from three cryopreserved cadavers were evaluated. Under ultrasound guidance, a 22-gauge needle was advanced in-plane along the long axis of the biceps tendon, targeting the interval between the coracohumeral ligament and intra-articular biceps tendon. Injectate spread was confirmed by dissection. Results: All six shoulders demonstrated accurate intra-articular injectate spread without intratendinous injection or unintended bursal accumulation. Conclusion: The long-axis RCI approach provides reliable intra-articular delivery with improved visualization and fewer traversed structures. Clinical studies are needed to establish its safety, reproducibility, and therapeutic outcomes.

Generalized joint hypermobility (GJH) is often challenging to assess, but its presence could suggest a syndromic diagnosis of Ehlers-Danlos Syndromes (EDS)

Background Pain and substance use frequently co-occur. Research indicates pain motivates alcohol, cannabis, and tobacco use. Pain is also highly co-morbid with Ehlers-Danlos Syndromes (EDS) and Generalized Hypermobility Spectrum Disorder (G-HSD), however, research on pain and substance use in these populations remains limited. Methods Descriptive, cross-sectional, retrospective chart review was conducted of 533 patients (89% female) seen at the GoodHope EDS Clinic at Toronto General Hospital and diagnosed with EDS or G-HSD. Patients provided self-report data on pain and substance use. Analyses included descriptive statistics and bivariate correlations. Results Half of the sample reported clinically significant pain severity (55%) and interference (57%). Alcohol use was reported by half of the sample (59%) and 18% reported prescription opioid use. Cannabis use was reported by 48%, with 69% using ≥ 4 times per week. Patients who used cigarettes (14%) smoked a median of 8.0 cigarettes per day (IQR = 4.0–12.0). Pain severity and interference were positively associated with cannabis use frequency, quantity, opioid use, and cigarette use (ρ = .13 – .28, ps < .05), and negatively associated with alcohol use (ρ = -.20 and -.20, ps < .05). Conclusions Greater pain severity and interference were associated with greater cannabis and cigarette use, but lower alcohol use. Longitudinal studies are needed to determine if pain is a motivator for cannabis/cigarette use and/or if persistent use exacerbates pain in this population. Research should also examine if negative associations between pain and alcohol use reflect alcohol analgesia (i.e., lower pain at greater drinking) or avoidance due to the exacerbation of co-occurring conditions with EDS/G-HSD.

Objective This case series aims to assess the analgesic effectiveness and safety of percutaneous chemical denervation of the articular branches on anterior hip capsule in patients with refractory hip pain secondary to avascular necrosis (AVN). Methods Nine patients with refractory chronic hip pain secondary to AVN underwent image-guided chemical neurolysis with 100% ethanol. Average pain scores were recorded at baseline, 1, 3 and 6 months after chemical neurolysis. Results The average baseline pain score was 6.7±1.2 on the Numerical Rating Scale (NRS). Two out of the nine patients did not respond to chemical neurolysis. For the seven patients who responded, the average NRS decreased to (2.9±1.2) at 1 month and (3.0±1.4) at 3 months. Five out of these seven patients maintained 50% or greater pain relief at both 1 and 3 months. For the five patients who completed the 6-month follow-up, the average NRS pain score was (3.0±1.7), with three of these patients maintaining 50% or greater pain relief. No one reported side effects or complications during the follow-up period. Conclusions In conclusion, alcohol neurolysis of the hip joint can be offered as an effective and safe modality for pain control in patients with AVN who failed conservative management. This small case series serves as a pilot for future large cohort studies.

Chronic primary musculoskeletal pain is prevalent and often the cause of medico-legal dispute. Pain with an unknown etiology that occurs in the absence of substantial tissue abnormality has challenged the health care community for decades. The World Health Organization now recognizes chronic primary pain (CPP) conditions as valid conditions that are prevalent and a cause of considerable suffering. Without an objective test or biomarker to confirm diagnosis or measure severity, CPP conditions may be brought before the Court with questions of severity, causation, functional impairment, and disablement. The many subjective symptoms that associate with CPP pain add to the total burden of illness and also to the complexity of the adjudication process. This review will discuss the responsibilities of clinicians when providing an opinion to aid a legal adjudication process. Medical information regarding CPP should be objectively and clearly stated, without bias and must remain within the practice domain of the clinician. The distinct roles of the treating clinician and the medico-legal expert will be compared. Issues concerning assessment of severity, validity measures to assess subjective symptoms, matters of causation, and impact on function are discussed. Irrespective of the legal setting, whether a regional tribunal or higher national court, the health care professional providing testimony must adhere to the highest ethical standards. Understanding the medico-legal process that functions in parallel, but differently from clinical care, will prepare health care professionals to provide relevant information that will lead to a fair and just outcome for those truly suffering with chronic pain.

Ehlers-Danlos Syndromes (EDS) and Generalized Hypermobility Spectrum disorders (G-HSD) are a group of genetic, connective multi-systemic disorders that can affect the musculoskeletal, gastrointestinal, cardiovascular, and respiratory systems. Respiratory manifestations in EDS/G-HSD can contribute to decrements in health-related quality of life (HRQL); however, these relationships have not been previously characterized. We aimed to review the association of respiratory manifestations with the physical, psychological, and social domains of HRQL in EDS/G-HSD. A comprehensive search was conducted using Ovid Medline, Embase, and CINAHL with the following terms: “Ehlers-Danlos Syndrome”, “Hypermobility Spectrum Disorders”, and “Quality of Life”. Selected studies in English that investigated the relationship between respiratory manifestations and HRQL domains in EDS/G-HSD were included in this narrative review from inception to March 2024. Twelve studies described the physical, psychological, or social domains of HRQL relating to respiratory manifestations. Dyspnea, wheezing, and expiratory flow limitations were associated with limitations in physical function and exercise intolerance. Respiratory manifestations were associated with increased fatigue, pain, anxiety, kinesiophobia, and deconditioning. This review highlights the consequences that respiratory manifestations have on the physical domains of HRQL, through limitations on physical activity and exercise. Future studies should aim to identify the impact that respiratory manifestations have on the psychosocial domains of HRQL and develop disease-specific patient-reported measures to evaluate these relationships.

Background: Injections for the piriformis and triceps coxae tendons/bursae have not been described and validated. Objective: To investigate the deep retrotrochanteric anatomy and validate an ultrasound (US)‐guided injection technique. Methods: Fifteen sides of the pelvic half/lower limb of formalin‐fixed cadaveric specimens were dissected to investigate the deep retrotrochanteric region. An US‐guided superficial/peritendinous green latex dye injection was performed on both sides of a single full body cadaver. Next, seven sides of another four full body cadavers were injected using a deep/intrabursal technique. The cadavers were dissected to observe the dye's location. Results: In the anatomical part of the study, we observed a consistent fusion of the piriformis tendon (PT) with the triceps coxae tendon (TCT) (15/15), and with the gluteus medius tendon in 93% (14/15). A bursa of piriformis was identified in 80% (12/15) of the cases, and a subtendinous bursa of obturator internus was found in 73% (11/15). A fat pad overlying the PT–TCT was present in 93% (14/15) of the cases. Regarding the US‐guided injections, success rate for superficial/peritendinous injection was 0% (0/2), with the latex dye being identified in the fat pad covering the PT–TCT in both cases. For the deep/intrabursal injection, the success rate was 86% (6/7). Conclusions: The results indicated a satisfactory success rate for the deep/intrabursal injection of PT–TCT in retrotrochanteric pain syndrome. This technique holds promise for the treatment of bursa and tendon pathologies in relevant patients.