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Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)—part I, shoulder



Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.


Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.


A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).


Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.

Key Points

• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder.

• The highest level of evidence was reached for five statements.

• Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).

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Acromioclavicular joint


Computed tomography


European Society of Musculoskeletal Radiology


External shockwave therapy


Glenohumeral joint


Long head of biceps tendon


Methylprednisolone acetate


Platelet-rich plasma


Rotator cuff calcific tendinopathy




Triamcinolone acetonide or triamcinolone acetate


Ultrasound-guided percutaneous irrigation of calcific tendinopathy


  1. 1.

    Gennaro N, Sconfienza LM, Ambrogi F, Boveri S, Lanza E (2019) Thermal ablation to relieve pain from metastatic bone disease: a systematic review. Skeletal Radiol 48:1161–1169.

  2. 2.

    Filippiadis DK, Marcia S, Masala S, Deschamps F, Kelekis A (2017) Percutaneous vertebroplasty and kyphoplasty: current status, new developments and old controversies. Cardiovasc Intervent Radiol 40:1815–1823.

  3. 3.

    Chianca V, Orlandi D, Messina C et al (2019) Interventional therapeutic procedures to treat degenerative and inflammatory musculoskeletal conditions: state of the art. Radiol Med.

  4. 4.

    Tagliafico A, Russo G, Boccalini S et al (2014) Ultrasound-guided interventional procedures around the shoulder. Radiol Med 119:318–326.

  5. 5.

    Pourcho AM, Colio SW, Hall MM (2016) Ultrasound-guided interventional procedures about the shoulder: anatomy, indications, and techniques. Phys Med Rehabil Clin N Am 27:555–572.

  6. 6.

    Messina C, Banfi G, Orlandi D et al (2016) Ultrasound-guided interventional procedures around the shoulder. Br J Radiol 89:20150372.

  7. 7.

    Silvestri E, Barile A, Albano D et al (2017) Interventional therapeutic procedures in the musculoskeletal system: an Italian survey by the Italian College of Musculoskeletal Radiology. Radiol Med.

  8. 8.

    Messina C, Orlandi D, Sconfienza LM (2016) Do we still need fluoroscopy to perform injections in the musculoskeletal system? Skeletal Radiol.

  9. 9.

    Messina C, Banfi G, Aliprandi A et al (2015) Ultrasound guidance to perform intra-articular injection of gadolinium-based contrast material for magnetic resonance arthrography as an alternative to fluoroscopy: the time is now. Eur Radiol.

  10. 10.

    Davidson J, Jayaraman S (2011) Guided interventions in musculoskeletal ultrasound: what’s the evidence? Clin Radiol 66:140–152.

  11. 11.

    Phadke A, Singh B, Bakti N (2019) Role of platelet rich plasma in rotator cuff tendinopathy—clinical application and review of literature. J Clin Orthop Trauma 10:244–247.

  12. 12.

    Sconfienza LM, Albano D, Allen G et al (2018) Clinical indications for musculoskeletal ultrasound updated in 2017 by European Society of Musculoskeletal Radiology (ESSR) consensus. Eur Radiol.

  13. 13.

    Klauser AS, Tagliafico A, Allen GM et al (2012) Clinical indications for musculoskeletal ultrasound: a Delphi-based consensus paper of the European society of musculoskeletal radiology. Eur Radiol 22:1140–1148.

  14. 14.

    Steurer J (2011) The Delphi method: an efficient procedure to generate knowledge. Skeletal Radiol 40:959–961.

  15. 15.

    Messina C, Bignotti B, Tagliafico A et al (2017) A critical appraisal of the quality of adult musculoskeletal ultrasound guidelines using the AGREE II tool: an EuroAIM initiative. Insights Imaging.

  16. 16.

    Messina C, Bignotti B, Bazzocchi A et al (2017) A critical appraisal of the quality of adult dual-energy X-ray absorptiometry guidelines in osteoporosis using the AGREE II tool: an EuroAIM initiative. Insights Imaging 8:311–317.

  17. 17.

    OCEBM Levels of Evidence Working Group. The Oxford 2011 levels of evidence

  18. 18.

    Lanza E, Banfi G, Serafini G et al (2015) Ultrasound-guided percutaneous irrigation in rotator cuff calcific tendinopathy: what is the evidence? A systematic review with proposals for future reporting. Eur Radiol 25:2176–2183.

  19. 19.

    Louwerens JK, Veltman ES, van Noort A, van den Bekerom MP (2016) The effectiveness of high-energy extracorporeal shockwave therapy versus ultrasound-guided needling versus arthroscopic surgery in the management of chronic calcific rotator cuff tendinopathy: a systematic review. Arthroscopy 32:165–175.

  20. 20.

    Arirachakaran A, Boonard M, Yamaphai S, Prommahachai A, Kesprayura S, Kongtharvonskul J (2017) Extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage, corticosteroid injection and combined treatment for the treatment of rotator cuff calcific tendinopathy: a network meta-analysis of RCTs. Eur J Orthop Surg Traumatol 27:381–390.

  21. 21.

    Gatt DL, Charalambous CP (2014) Ultrasound-guided barbotage for calcific tendonitis of the shoulder: a systematic review including 908 patients. Arthroscopy 30:1166–1172.

  22. 22.

    Orlandi D, Mauri G, Lacelli F et al (2017) Rotator cuff calcific tendinopathy: randomized comparison of US-guided percutaneous treatments by using one or two needles. Radiology.

  23. 23.

    Sconfienza LM, Bandirali M, Serafini G et al (2012) Rotator cuff calcific tendinitis: does warm saline solution improve the short-term outcome of double-needle US-guided treatment? Radiology 262:560–566.

  24. 24.

    de Witte PB, Selten JW, Navas A et al (2013) Calcific tendinitis of the rotator cuff. Am J Sports Med 41:1665–1673.

  25. 25.

    Rha DW, Park GY, Kim YK, Kim MT, Lee SC (2013) Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil 27:113–122.

  26. 26.

    Lin CL, Huang CC, Huang SW (2018) Effects of hypertonic dextrose injection on chronic supraspinatus tendinopathy of the shoulder: randomized placebo-controlled trial. Eur J Phys Rehabil Med.

  27. 27.

    Seven MM, Ersen O, Akpancar S et al (2017) Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthop Traumatol Surg Res 103:427–433.

  28. 28.

    Cole B, Lam P, Hackett L, Murrell GAC (2018) Ultrasound-guided injections for supraspinatus tendinopathy: corticosteroid versus glucose prolotherapy—a randomized controlled clinical trial. Shoulder Elbow 10:170–178.

  29. 29.

    Hashiuchi T, Sakurai G, Morimoto M, Komei T, Takakura Y, Tanaka Y (2011) Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg 20:1069–1073.

  30. 30.

    Petscavage-Thomas J, Gustas C (2016) Comparison of ultrasound-guided to fluoroscopy-guided biceps tendon sheath therapeutic injection. J Ultrasound Med 35:2217–2221.

  31. 31.

    Aly AR, Rajasekaran S, Ashworth N (2015) Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med 49:1042–1049.

  32. 32.

    Sconfienza LM, Mauri G, Messina C et al (2016) Ultrasound-guided percutaneous tenotomy of biceps tendon: technical feasibility on cadavers. Ultrasound Med Biol.

  33. 33.

    Atlan F, Werthel JD (2016) Ultrasound-guided intra-articular tenotomy of the long head of the biceps: a cadaveric feasibility study. Int Orthop 40:2567–2573.

  34. 34.

    Lévy B, Ducat A, Gaudin P et al (2012) Ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon: a non-reliable technique. Knee Surg Sports Traumatol Arthrosc 20:1027–1030.

  35. 35.

    Greditzer HG, Kaplan LD, Lesniak BP, Jose J (2014) Ultrasound-guided percutaneous long head of the biceps tenotomy: a novel technique with case report. HSS J 10:240–244.

  36. 36.

    Doss A (2013) Neotendon infilling of a full thickness rotator cuff foot print tear following ultrasound guided liquid platelet rich plasma injection and percutaneous tenotomy: favourable outcome up to one year. F1000Res 2:23.

  37. 37.

    Mautner K, Colberg RE, Malanga G et al (2013) Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PM R 5:169–175.

  38. 38.

    Scarpone M, Rabago D, Snell E et al (2013) Effectiveness of platelet-rich plasma injection for rotator cuff tendinopathy: a prospective open-label study. Glob Adv Health Med 2:26–31.

  39. 39.

    Tahririan MA, Moezi M, Motififard M, Nemati M, Nemati A (2016) Ultrasound guided platelet-rich plasma injection for the treatment of rotator cuff tendinopathy. Adv Biomed Res 5:200.

  40. 40.

    Cai YU, Sun Z, Liao B, Song Z, Xiao T, Zhu P (2019) Sodium hyaluronate and platelet-rich plasma for partial-thickness rotator cuff tears. Med Sci Sports Exerc 51:227–233.

  41. 41.

    Wesner M, Defreitas T, Bredy H et al (2016) A pilot study evaluating the effectiveness of platelet-rich plasma therapy for treating degenerative tendinopathies: a randomized control trial with synchronous observational cohort. PLoS One 11:1–14.

  42. 42.

    Hak A, Rajaratnam K, Ayeni OR et al (2015) A double-blinded placebo randomized controlled trial evaluating short-term efficacy of platelet-rich plasma in reducing postoperative pain after arthroscopic rotator cuff repair: a pilot study. Sports Health 7:58–66.

  43. 43.

    Ebert JR, Wang A, Smith A et al (2017) A midterm evaluation of postoperative platelet-rich plasma injections on arthroscopic supraspinatus repair: a randomized controlled trial. Am J Sports Med 45:2965–2974.

  44. 44.

    Wang A, Mccann P, Colliver J et al (2015) Do postoperative platelet-rich plasma injections accelerate early tendon healing and functional recovery after arthroscopic supraspinatus repair?: a randomized controlled trial. Am J Sports Med 43:1430–1437.

  45. 45.

    Cunnington J, Marshall N, Hide G et al (2010) A randomised, controlled, double blinded study of ultrasound guided corticosteroid joint injection in patients with inflammatory arthritis. Arthritis Rheum 62:NA-NA.

  46. 46.

    A Jones A, Regan M, Ledingham J, Pattrick M, Manhire A, Doherty M (1993) Importance of placement of intra-articular steroid injections. BMJ 307:1329–1330.

  47. 47.

    Sethi PM, Kingston S, Elattrache N (2005) Accuracy of anterior intra-articular injection of the glenohumeral joint. Arthroscopy 21:77–80.

  48. 48.

    Catalano OA, Manfredi R, Vanzulli A et al (2007) MR arthrography of the glenohumeral joint: modified posterior approach without imaging guidance. Radiology 242:550–554.

  49. 49.

    Lopes RV, Furtado RN, Parmigiani L, Rosenfeld A, Fernandes AR, Natour J (2008) Accuracy of intra-articular injections in peripheral joints performed blindly in patients with rheumatoid arthritis. Rheumatology (Oxford) 47:1792–1794.

  50. 50.

    Jo CH, Shin YH, Shin JS (2011) Accuracy of intra-articular injection of the glenohumeral joint: a modified anterior approach. Arthroscopy 27:1329–1334.

  51. 51.

    Porat S, Leupold JA, Burnett KR, Nottage WM (2008) Reliability of non-imaging-guided glenohumeral joint injection through rotator interval approach in patients undergoing diagnostic MR arthrography. AJR Am J Roentgenol 191:W96–W99.

  52. 52.

    Tobola A, Cook C, Cassas KJ et al (2011) Accuracy of glenohumeral joint injections: comparing approach and experience of provider. J Shoulder Elbow Surg 20:1147–1154.

  53. 53.

    Johnson TS, Mesfin A, Farmer KW et al (2011) Accuracy of intra-articular glenohumeral injections: the anterosuperior technique with arthroscopic documentation. Arthroscopy 27:745–749.

  54. 54.

    Gokalp G, Dusak A, Yazici Z (2010) Efficacy of ultrasonography-guided shoulder MR arthrography using a posterior approach. Skeletal Radiol 39:575–579.

  55. 55.

    Perdikakis E, Drakonaki E, Maris T, Karantanas A (2013) MR arthrography of the shoulder: tolerance evaluation of four different injection techniques. Skeletal Radiol 42:99–105.

  56. 56.

    Rutten MJ, Collins JM, Maresch BJ et al (2009) Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography. Eur Radiol 19:722–730.

  57. 57.

    Souza PM, Aguiar RO, Marchiori E, Bardoe SA (2010) Arthrography of the shoulder: a modified ultrasound guided technique of joint injection at the rotator interval. Eur J Radiol 74:e29–e32.

  58. 58.

    Patel DN, Nayyar S, Hasan S, Khatib O, Sidash S, Jazrawi LM (2012) Comparison of ultrasound-guided versus blind glenohumeral injections: a cadaveric study. J Shoulder Elbow Surg 21:1664–1668.

  59. 59.

    Lee HJ, Lim KB, Kim DY, Lee KT (2009) Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Arch Phys Med Rehabil 90:1997–2002.

  60. 60.

    Prestgaard T, Wormgoor ME, Haugen S, Harstad H, Mowinckel P, Brox JI (2015) Ultrasound-guided intra-articular and rotator interval corticosteroid injections in adhesive capsulitis of the shoulder: a double-blind, sham-controlled randomized study. Pain 156:1683–1691.

  61. 61.

    Gyftopoulos S, Abballe V, Virk MS, Koo J, Gold HT, Subhas N (2018) Comparison between image-guided and landmark-based glenohumeral joint injections for the treatment of adhesive capsulitis: a cost-effectiveness study. AJR Am J Roentgenol 210:1279–1287.

  62. 62.

    Partington PF, Broome GH (1998) Diagnostic injection around the shoulder: hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg 7:147–150

  63. 63.

    Pichler W, Weinberg AM, Grechenig S, Tesch NP, Heidari N, Grechenig W (2009) Intra-articular injection of the acromioclavicular joint. J Bone Joint Surg Br 91:1638–1640.

  64. 64.

    Sabeti-Aschraf M, Lemmerhofer B, Lang S et al (2011) Ultrasound guidance improves the accuracy of the acromioclavicular joint infiltration: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc 19:292–295.

  65. 65.

    Borbas P, Kraus T, Clement H, Grechenig S, Weinberg AM, Heidari N (2012) The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers. J Shoulder Elbow Surg 21:1694–1697.

  66. 66.

    Bisbinas I, Belthur M, Said HG, Green M, Learmonth DJ (2006) Accuracy of needle placement in ACJ injections. Knee Surg Sports Traumatol Arthrosc 14:762–765.

  67. 67.

    Javed S, Sadozai Z, Javed A, Din A, Schmitgen G (2017) Should all acromioclavicular joint injections be performed under image guidance? J Orthop Surg (Hong Kong) 25:2309499017731633.

  68. 68.

    Scillia A, Issa K, McInerney VK et al (2015) Accuracy of in vivo palpation-guided acromioclavicular joint injection assessed with contrast material and fluoroscopic evaluations. Skeletal Radiol 44:1135–1139.

  69. 69.

    Park KD, Kim TK, Lee J, Lee WY, Ahn JK, Park Y (2015) Palpation versus ultrasound-guided acromioclavicular joint intra-articular corticosteroid injections: a retrospective comparative clinical study. Pain Physician 18:333–341

  70. 70.

    van Riet RP, Goehre T, Bell SN (2012) The long term effect of an intra-articular injection of corticosteroids in the acromioclavicular joint. J Shoulder Elbow Surg 21:376–379.

  71. 71.

    Hossain S, Jacobs LG, Hashmi R (2008) The long-term effectiveness of steroid injections in primary acromioclavicular joint arthritis: a five-year prospective study. J Shoulder Elbow Surg 17:535–538.

  72. 72.

    Cadogan A, McNair P, Laslett M, Hing W (2013) Shoulder pain in primary care: diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain. BMC Musculoskelet Disord 14:156.

  73. 73.

    Sabeti-Aschraf M, Ochsner A, Schueller-Weidekamm C et al (2010) The infiltration of the AC joint performed by one specialist: ultrasound versus palpation a prospective randomized pilot study. Eur J Radiol 75:e37–e40.

  74. 74.

    Sabeti-Aschraf M, Stotter C, Thaler C et al (2013) Intra-articular versus periarticular acromioclavicular joint injection: a multicenter, prospective, randomized, controlled trial. Arthroscopy 29:1903–1910.

  75. 75.

    Weinberg AM, Pichler W, Grechenig S, Tesch NP, Heidari N, Grechenig W (2009) Frequency of successful intra-articular puncture of the sternoclavicular joint: a cadaver study. Scand J Rheumatol 38:396–398.

  76. 76.

    Pourcho AM, Sellon JL, Smith J (2015) Sonographically guided sternoclavicular joint injection: description of technique and validation. J Ultrasound Med 34:325–331.

  77. 77.

    Peterson CK, Saupe N, Buck F, Pfirrmann CW, Zanetti M, Hodler J (2010) CT-guided sternoclavicular joint injections: description of the procedure, reliability of imaging diagnosis, and short-term patient responses. AJR Am J Roentgenol 195:W435–W439.

  78. 78.

    Elkousy H, Gartsman GM, Drake G, Sola W Jr, O'Connor D, Edwards TB (2011) Retrospective comparison of freehand and ultrasound-guided shoulder steroid injections. Orthopedics 34:270–270.

  79. 79.

    Zufferey P, Revaz S, Degailler X, Balague F, So A (2012) A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain. Joint Bone Spine 79:166–169.

  80. 80.

    Wu T, Song HX, Dong Y, Li JH (2015) Ultrasound-guided versus blind subacromial–subdeltoid bursa injection in adults with shoulder pain: a systematic review and meta-analysis. Semin Arthritis Rheum 45:374–378.

  81. 81.

    Bhayana H, Mishra P, Tandon A, Pankaj A, Pandey R, Malhotra R (2018) Ultrasound guided versus landmark guided corticosteroid injection in patients with rotator cuff syndrome: randomised controlled trial. J Clin Orthop Trauma 9:S80–S85.

  82. 82.

    Daniels EW, Cole D, Jacobs B, Phillips SF (2018) Existing evidence on ultrasound-guided injections in sports medicine. Orthop J Sports Med 6:232596711875657.

  83. 83.

    Steuri R, Sattelmayer M, Elsig S et al (2017) Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med 51:1340–1347.

  84. 84.

    Soh E, Li W, Ong KO, Chen W, Bautista D (2011) Image-guided versus blind corticosteroid injections in adults with shoulder pain: a systematic review. BMC Musculoskelet Disord 12:137.

  85. 85.

    Sage W, Pickup L, Smith TO, Denton ER, Toms AP (2013) The clinical and functional outcomes of ultrasound-guided vs landmark-guided injections for adults with shoulder pathology—a systematic review and meta-analysis. Rheumatology (Oxford) 52:743–751.

  86. 86.

    Haghighat S, Taheri P, Banimehdi M, Taghavi A (2015) Effectiveness of blind & ultrasound guided corticosteroid injection in impingement syndrome. Global J Health Sci 8:179.

  87. 87.

    Naredo E, Cabero F, Beneyto P et al (2004) A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 31:308–314

  88. 88.

    Ucuncu F, Capkin E, Karkucak M et al (2009) A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain. Clin J Pain 25:786–789.

  89. 89.

    Hsieh LF, Hsu WC, Lin YJ, Wu SH, Chang KC, Chang HL (2013) Is ultrasound-guided injection more effective in chronic subacromial bursitis? Med Sci Sports Exerc 45:2205–2213.

  90. 90.

    Saeed A, Khan M, Morrissey S, Kane D, Fraser AD (2014) Impact of outpatient clinic ultrasound imaging in the diagnosis and treatment for shoulder impingement: a randomized prospective study. Rheumatol Int 34:503–509.

  91. 91.

    Bloom JE, Rischin A, Johnston RV, Buchbinder R (2012) Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev:CD009147.

  92. 92.

    Bookman JS, Pereira DS (2014) Ultrasound guidance for intra-articular knee and shoulder injections: a review. Bull Hosp Jt Dis (2013) 72:266–270

  93. 93.

    Chávez-López MA, Navarro-Soltero LA, Rosas-Cabral A, Gallaga A, Huerta-Yáñez G (2009) Methylprednisolone versus triamcinolone in painful shoulder using ultrasound-guided injection. Mod Rheumatol 19:147–150.

  94. 94.

    Battaglia M, Guaraldi F, Gori D, Castiello E, Arvat E, Sudanese A (2017) Efficacy of triamcinolone acetate and methylprednisolone acetonide for intrabursal injection after ultrasound-guided percutaneous treatment in painful shoulder calcific tendonitis: a randomized controlled trial. Acta Radiol 58:964–970.

  95. 95.

    Carroll MB, Motley SA, Smith B, Ramsey BC, Baggett AS (2018) Comparing corticosteroid preparation and dose in the improvement of shoulder function and pain. Am J Phys Med Rehabil 97:450–455.

  96. 96.

    Meloni F, Milia F, Cavazzuti M et al (2008) Clinical evaluation of sodium hyaluronate in the treatment of patients with supraspinatus tendinosis under echographic guide: experimental study of periarticular injections. Eur J Radiol 68:170–173.

  97. 97.

    Chou W-Y, Ko J-Y, Wang F-S et al (2010) Effect of sodium hyaluronate treatment on rotator cuff lesions without complete tears: a randomized, double-blind, placebo-controlled study. J Shoulder Elbow Surg 19:557–563.

  98. 98.

    Moghtaderi A, Sajadiyeh S, Khosrawi S, Dehghan F, Bateni V (2013) Effect of subacromial sodium hyaluronate injection on rotator cuff disease: a double-blind placebo-controlled clinical trial. Adv Biomed Res 2:89.

  99. 99.

    Huang YC, Leong CP, Wang L et al (2016) The effects of hyaluronic acid on hemiplegic shoulder injury and pain in patients with subacute stroke: a randomized controlled pilot study. Medicine (Baltimore) 95:e5547.

  100. 100.

    Penning LI, de Bie RA, Walenkamp GH (2012) The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement: a three-arm randomised controlled trial. J Bone Joint Surg Br 94:1246–1252.

  101. 101.

    Penning LI, de Bie RA, Walenkamp GH (2014) Subacromial triamcinolone acetonide, hyaluronic acid and saline injections for shoulder pain an RCT investigating the effectiveness in the first days. BMC Musculoskelet Disord 15:352.

  102. 102.

    Peterson C, Hodler J (2010) Evidence-based radiology (part 2): is there sufficient research to support the use of therapeutic injections into the peripheral joints? Skeletal Radiol 39:11–18.

  103. 103.

    Wallis CJD, Detsky AS, Fan E (2018) Establishing the effectiveness of procedural interventions: the limited role of randomized trials. JAMA 320:2421.

  104. 104.

    Hartrick CT (2008) Quality assessment in clinical trials: considerations for outcomes research in interventional pain medicine. Pain Pract 8:433–438.

  105. 105.

    Tagliafico AS, Wilson D, Sconfienza LM, European Society of Musculoskeletal Radiology (ESSR) Research Committee (2019) Encouraging MSK imaging research towards clinical impact is a necessity: opinion paper of the European Society of Musculoskeletal Radiology (ESSR). Eur Radiol 29:3410–3413.

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All authors are members of the Ultrasound and/or Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR).


The authors state that this work has not received any funding.

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Correspondence to Luca Maria Sconfienza.

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The scientific guarantor of this publication is Luca Maria Sconfienza, MD PhD.

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Sconfienza, L.M., Adriaensen, M., Albano, D. et al. Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)—part I, shoulder. Eur Radiol 30, 903–913 (2020).

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  • Interventional radiology
  • Shoulder
  • Ultrasonography
  • Injections
  • Platelet-rich plasma