1. بسم الله الرحمن الرحیم 1

2. A randomized prospective comparative study of four methods of biceps tendinitis treatment: US, LLL/US, intra-sheath and extra- sheath corticosteroid guided injection Mohsen Mardani-Kivi, M.D. Associate Professor 2 Orthopedic Department, Guilan University Of Medical Sciences

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4. Background 4 Best treatment method? –US –LLL+US –Guided CSI Intasheath vs. Extrasheath (Does it really matter?)

5. The purpose of the study to compare the therapeutic effects between four methods of US alone or in combination with LLLT (L/US), intra and extra sheath US guided injection in treatment of LHB tendonitis. 5

6. 4-groups parallel RCT inclusion criteria: 22-60y years, pain continued more than 3 months, local tenderness in bicipital groove, at least one biceps positive test. Exclusion criteria: history of trauma, injection or surgery in affected shoulder, calcification in rotator cuff, and any signs of partial or complete dislocations or raptures of LHB 6

7. US group: 10 sessions of US with frequency of 1MHz and intensity of 1 W/cm 2 by pulse mode duty cycle of 2:8 and probe surface of 5 cm 2 were applied for 5 min in each section LLT+US: infrared laser with pencil probe gallium arsenide aluminum (830 nm wave length, 30 mW power, 1 J/cm 2 intensity, 4 mm ray diameter, and 2.5° angle of divergence) InCI: linear probe, 2-20, 1ml of 40 mg/ml methyl prednisolone acetate solution and 1 ml of 2% lidocaine solution ExCI: similar to InCI, solution was injected extra tendon sheath. 7

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11. primary and secondary outcome Primary outcome: Pain intensity => VASSecondary outcome: Shoulder function => CMS 11

12. Results Baseline assessment 12

13. Results 13

14. Discussion Zhang etal.: higher accuracy of injection under US guidance could be the cause of better results in guided group in comparison to blinded group Present study: One week after treatment, pain intensity in the InCI group was significantly lower than the other 3 groups. However, after 3 weeks this difference between this group and ExCI disappeared. Zhang J, etal. Ultrasound in medicine & biology. 2011;37(5):729-33. 14

15. Discussion Hashiuchi et al.: Injection under US guidance had higher accuracy against blinded injection. Hashiuchi T etal. Journal of shoulder and elbow 2011;20(7):1069-73. It seems that intra tendon sheath corticosteroid injection has no advantages against extra tendon sheath injection with regard to shoulder function 15

16. Discussion Otadi et al. : Better further effectiveness of L/US against US. LLLT+US produce better and more rapid results than US alone. When the therapist does not have enough expertise in local injection, it is better to use L/US and not US alone in treatment of LHB tendonitis. 16 Hashiuchi T etal. Journal of shoulder and elbow 2011;20(7):1069-73.

17. Discussion DM has no effects on the treatment trend of LHB tendonitis. Intensity of activity has no effect on trend of improvement 17

18. Limitations 1- low number of DM and non-DM patients 2- lack of complete blindness of patients. 3- Concurrent existence of inflammatory diseases of shoulder joint (arthritis or capsulitis) 4- Possibility of using other drugs or traditional medicinal agents as arbitrary and secret. 18

19. Take home message Although US guided InCI is an effective method for LHB tendonitis, but ExCI also has acceptable results. Using L/US as a less invasive treatment could be as effective as corticosteroid injection in the long term. 19

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