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Diagnostic and therapeutic injection of the shoulder region -- american family physicianDiagnostic and Therapeutic Injection
of the Shoulder Region
ALFRED F. TALLIA, M.D., M.P.H., and DENNIS A. CARDONE, D.O., C.A.Q.S.M., University of Medicine
and Dentistry of New Jersey–Robert Wood Johnson Medical School, New Brunswick, New Jersey
The shoulder is the site of multiple injuries and inflammatory conditions that lend them-
selves to diagnostic and therapeutic injection. Joint injection should be considered after
other therapeutic interventions such as nonsteroidal anti-inflammatory drugs, physical
therapy, and activity- modification have been tried. Indications for glenohumeral joint injec-
tion include osteoarthritis, adhesive capsulitis, and rheumatoid arthritis. For the acromio-
clavicular joint, injection may be used for diagnosis and treatment of osteoarthritis and dis-
tal clavicular osteolysis. Subacromial injections are useful for a range of conditions
including adhesive capsulitis, subdeltoid bursitis, impingement syndrome, and rotator cuff
tendinosis. Scapulothoracic injections are reserved for inflammation of the involved bursa.
Persistent pain related to inflammatory conditions of the long head of the biceps responds
well to injection in the region. The proper technique, choice and quantity of pharmaceuti-
cals, and appropriate follow-up are essential for effective outcomes. (Am Fam Physician
2003;67:1271-8. Copyright 2003 American Academy of Family Physicians.)
number of ligaments and muscles, including the four muscles of the rotator cuff (supra- spinatus, infraspinatus, teres minor, and sub- nated by Dennis A.
Cardone, D.O.,C.A.Q.S.M., associateprofessor, and Alfred F. diagnostic and therapeutic in-jections, covers the shoulder re-gion. The rationale, indications, scapularis) that serve as dynamic stabilizers of the joint. Static stabilizers include the joint approach to this technique are covered in the capsule, the glenoid labrum, and the gleno- first article1 in this series published in the July 15, 2002 issue. The shoulder is the site of mul- INDICATIONS AND DIAGNOSIS
tiple injuries and inflammatory conditions Medicine, UMDNJ–Robert Wood Johnson that lend themselves to diagnostic and thera- Joint injection in this area should be con- peutic injection.2-4 This article covers the sidered only after other appropriate therapeu- anatomy, pathology, diagnosis, and injection technique of common sites in which this skill include the use of nonsteroidal anti-inflam- matory drugs (NSAIDs), physical therapy, andother disease-modifying agents for rheuma- Glenohumeral Joint
toid arthritis. There are three major indica- tions for a glenohumeral joint injection: articulation of the humerus with the glenoid osteoarthritis, adhesive capsulitis (frozen fossa, and it is the most mobile joint in the shoulder),5-14 and rheumatoid arthritis.11 body. The glenohumeral joint is not a true ball and socket joint. The articulation is stabi- occurs in older persons or following trau- lized by the soft tissue configurations of a matic injury in younger persons. Patientsusually present with chronic pain, decreasedrange of motion, and accompanying weak-ness. Although radiographs can assist in the The major indications for glenohumeral joint injection diagnosis, findings do not always correlate include osteoarthritis, adhesive capsulitis (frozen shoulder), with clinical symptoms or functioning. Adhe- sive capsulitis is a condition typically occur-ring in middle-aged and older adults, and it is usually associated with a traumatic injury or nation, the physician may find painful and nonuse of the shoulder secondary to pain, decreased range of motion, generalized weak- discomfort, or prolonged immobilization.
ness, and palpable crepitus with shoulder movement.15 Radiographs may be helpful in and persons with diabetes.12 There is often confirming the diagnosis. Historical factors accompanying tendinosis or bursitis.
also cue the diagnosis, with osteoarthritis Rheumatoid arthritis is a systemic inflamma- being more insidious in onset, and rheuma- toid arthritis, while chronic in nature, being involves inflammation of the synovium of the punctuated by periodic exacerbations sec- ondary to inflammation. In adhesive capsuli- Diagnosis of glenohumeral joint pathology tis, progressive worsening of pain occurs is suspected clinically, and on physical exami- with loss of motion and a firm, painful end TABLE 1
Equipment and Pharmaceuticals
1 to 2mL betamethasone sodium phosphate 150 to 300 *—Other preparations such as triamcinolone or dexamethasone may be used. Shoulder Joint Injection
FIGURE 1. (Left) Anterior approach to the glenohumeral joint. (Right) Posterior approach to theglenohumeral joint.
point in the range of motion during physicalexamination.
Corticosteroid Preparations for Therapeutic Injection
from an anterior, posterior, or superior ap- Compound (in order of relative solubility) proaches, which are used more often, aredescribed here. In each case, the joint is most easily accessible with the patient sitting, the patient’s arm resting comfortably at the side, and the shoulder externally rotated. Essential landmarks to palpate before performing this injection include the head of the humerus, the Sterile technique must be followed. Phar- Anterior Approach. The needle (Figure 1) should be placed just medial to the head of the process. The needle is directed posteriorly and slightly superiorly and laterally. If the needlehits against bone, it should be pulled back and redirected at a slightly different angle.
Adapted with permission from Klippel JH, Weyand, CM, Wortmann R. Primer on Posterior Approach. The needle (Figure 1) the rheumatic diseases. 11th ed. Atlanta: Arthritis Foundation, 1997:420. should be inserted 2 to 3 cm inferior to the Acromioclavicular Joint
Indications for acromioclavicular joint injection include osteolysis of the distal clavicle and osteoarthritis. diarthrodial joint that connects the acromionto the distal clavicle. The AC ligament is weakand provides little joint stability. Rather, the posterolateral corner of the acromion and directed anteriorly in the direction of the conoid ligaments) provides the major struc- coracoid process. As with any injection, aspi- tural support for the joint and is the primary ration should be done to ensure that there has ligament injured in an AC sprain, otherwise not been needle placement in the blood ves- sel. The injection should be performed slowly,but with consistent pressure.
INDICATIONS AND DIAGNOSIS
Follow-up care should include the follow- should be performed only after a trial of other main seated or placed in supine position for therapeutic modalities such as relative rest, several minutes after the injection. To ascer- activity modification, and NSAIDs. Indica- tain whether the pharmaceuticals have been tions for injection of the AC joint include delivered to the appropriate location, the osteolysis of the distal clavicle and osteo- arthritis.17 Osteolysis of the distal clavicle is a range of motion. The patient should remain degenerative process that results in chronic in the office to be monitored for 30 minutes pain, particularly with adduction movements after the injection, and the patient should of the shoulder. Osteolysis of the distal clavi- cle is typically seen secondary to traumatic injected region for at least 48 hours. Patients injury or in persons who perform repetitive should be cautioned that they might experi- weight training involving the shoulder.
ence worsening symptoms during the first Osteoarthritis also may develop in the AC 24 to 48 hours, related to a possible steroid joint and typically develops secondary to pre- NSAIDs. A follow-up examination should be important in making the diagnosis of osteol-ysis of the distal clavicle or osteoarthritis. Ineach condition, patients usually have insidi-ous onset of pain. On physical examination, there is tenderness to palpation of the AC ALFRED F. TALLIA, M.D., M.P.H., is associate professor and vice chair in the department joint, and pain with active or passive adduc- of family medicine at the University of Medicine and Dentistry of New Jersey(UMDNJ)–Robert Wood Johnson Medical School, New Brunswick, N.J. Dr. Tallia is a tion (reaching the arm across the body) of the graduate of the UMDNJ–Robert Wood Johnson Medical School and completed his res- shoulder. Pain can be exacerbated by having idency at the Thomas Jefferson University Family Medicine Residency, Philadelphia, Pa.
the patient hold the opposite shoulder and He received his public health degree at Rutgers University, New Brunswick, N.J. pushing the elbow toward the ceiling against DENNIS A. CARDONE, D.O., C.A.Q.S.M., is associate professor and director of sports resistance. Radiographs of the AC joint will medicine and the sports medicine fellowship in the department of family medicine atUMDNJ–Robert Wood Johnson Medical School. Dr. Cardone is a graduate of the New York College of Osteopathic Medicine, Old Westbury, N.Y., and completed his resi- dency at the UMDNJ–Robert Wood Johnson Medical School Family Medicine Resi- In some cases, it may be difficult to differ- dency. He completed his sports medicine fellowship at UMDNJ. entiate pain from AC joint pathology from Address correspondence to Alfred F. Tallia, M.D., M.P.H., Dept. of Family Medicine, other shoulder pathology, particularly rotator UMDNJ, 1 Robert Wood Johnson Pl., MEB 288, New Brunswick, NJ 08903 (e-mail: tal-lia @umdnj.edu). Reprints are not available from the authors. cuff impingement syndrome. Injecting 5 mL Shoulder Joint Injection
and is a contributor to impingement syn-drome. The susceptibility to impingementsyndrome increases as the degree of curve inthe acromion increases.
INDICATIONS AND DIAGNOSIS
Typically, a subacromial injection is per- formed after a trial of more conservative ther-apy.18 For the patient who presents with severepain and acute onset of symptoms consistentwith subdeltoid bursitis, the best treatmentplan may be injection at the initial visit. Persis-tent pain unresponsive to therapy, includinginjection therapy, should prompt the physician to consider other causes, such as Parsonage-Turner syndrome, a rare disorder of unknown of 1 percent lidocaine (Xylocaine) into the cause that involves chronic shoulder pain.
subacromial space to eliminate this as the source of pain is a useful test. If pain is still injection in this area are subdeltoid bursitis, present, the test localizes the AC joint as the rotator cuff impingement, rotator cuff tendi- probable source of pain. Patients with osteol- nosis, and adhesive capsulitis.19 Subdeltoid ysis or arthritis of the AC joint will not have bursitis (or subacromial bursitis) can be the temporary relief of symptoms following the result of traumatic injury or chronic overuse, and it frequently accompanies other shoulderproblems. A history of pain in the lateral TECHNIQUE
shoulder and tenderness to palpation along Patients are placed in the supine or seated the acromial border indicates a diagnosis of position with the affected arm resting com- fortably at their side. To identify the AC joint, palpate the clavicle distally to its termination nosis, results from acute or chronic stress of at which point a slight depression will be felt the rotator cuff tendons. Rotator cuff im- at the joint articulation. Aseptic technique is pingement results from repeated irritation of followed. Pharmaceuticals and equipment are the rotator cuff beneath the acromial arch.20 listed in Tables 1 and 2.16 The needle is inserted from the superior and anterior approach into training are frequent precipitants of rotator the AC joint and directed inferiorly (Figure 2). The pharmaceutical solution is injected evenly cuff tendinosis is diagnosed by eliciting pain and slowly. Follow-up care is the same as or weakness with stress testing of the rotator described for the glenohumeral joint.
cuff muscles. There are two common testsused for diagnosis of impingement. The Subacromial Space
Hawkins’ test elicits pain with the shoulder Important structures defining the subacro- passively flexed to 90 degrees and internally mial space include the acromion, subdeltoid rotated.21 The Neer’s test elicits pain with bursa, coracoacromial ligament, and supra- passive abduction of the shoulder to 180 de- grees.22 Radiographs, if obtained, may show greater tuberosity of the humerus. The shape calcific deposits in the subacromial space or of the acromion affects the subacromial space at the insertion of the supraspinatus tendon TECHNIQUE
Increased range of motion and strength following subacromial The distal, lateral, and posterior edges of injection with lidocaine usually points to a diagnosis of an the acromion are palpated. Pharmaceuticals impingement syndrome rather than a tear of the rotator cuff. and equipment are listed in Tables 1 and 2.16Using aseptic technique, the needle is insertedjust inferior to the posterolateral edge of the to the greater tuberosity. In cases of impinge- acromion (Figure 3). The needle is directed ment, curvature of the acromion process may toward the opposite nipple. The pharmaceu- tical material should flow freely into the space Adhesive capsulitis can also be treated with without any resistance or significant discom- fort to the patient. Follow-up care is the same bursa is involved in most cases of adhesive capsulitis.23 For adhesive capsulitis, the use ofa subacromial corticosteroid injection should Scapulothoracic Articulation
This is not a true joint, but rather repre- sents the position of the scapula on the poste- At times, it may be difficult to differentiate rior thoracic cage on which it freely moves.
the diagnosis of shoulder pain. Subacromial Lateral to the inferior medial border of the injection can be used for diagnostic pur- scapula is a bursa that can become inflamed.
poses. Injecting 5 mL of 1 percent lidocaineinto the subacromial space can help differ- INDICATIONS AND DIAGNOSIS
entiate rotator cuff tendinosis or impinge- Injection is performed after a trial of other ment from other shoulder disorders, such as modalities, including NSAIDs, strengthening of the rotator cuff, and the scapular stabilizer acromioclavicular joints and labral or rota- muscles. This area is the site of inflammation tor cuff tears. Patients with tendinosis or associated with various activities, including impingement will have temporary relief of throwing, weight lifting, and activities, of daily symptoms and will have increased range of living involving pushing or pulling.24 Diagno- motion and strength following the injection.
sis is assisted by obtaining a history of painwith any of the above activities, which fre-quently will cause the sensation of popping orcatching with the offending motion. Palpationof the area may reveal tenderness on the infe-rior medial border of the scapula, as well ascrepitus with movement or compression ofthe scapula against the chest wall.
The patient is placed in the prone position with the ipsilateral hand placed on the buttockto open up the scapulothoracic space. The infe-rior medial border of the scapula is then pal-pated. Aseptic technique is used. Pharmaceuti-cals and equipment are listed in Tables 1 and 2.16The needle is inserted along the inferior medial border of the scapula and directed parallel to the Shoulder Joint Injection
Persistent pain secondary to inflammation of the bicipitaltendon that is unresponsive to conservative therapy is anindication for injection. INDICATIONS AND DIAGNOSIS
after the patient has failed all conservativetreatments, including NSAIDs, avoidance ofprecipitating activities, and a course of physi-cal therapy. Repeat injections should beavoided because of the possibility of tendonrupture. Underlying rotator cuff pathologies FIGURE 4. Scapulothoracic articulation.
Persistent pain secondary to inflammation plane of the undersurface of the scapula, not of the bicipital tendon is an indication for ther- toward the chest wall (Figure 4). Follow-up care apeutic injection. Diagnosis is usually made by is the same as previously described.
eliciting pain with palpation of the tendonalong the bicipital groove to its origin. A posi- Long Head of the Biceps Tendon
tive Speed’s test is the elicitation of pain with The long head of the biceps tendon travels the patient’s shoulder flexed to 60 degrees, through the bicipital groove to insert on the elbow extended to 150 to 160 degrees, palm head of the humerus.25 This is a site for in- supinated, and pushing up against resistance.
flammation with any repetitive motion in-volving flexion of the shoulder. Weight lifters, TECHNIQUE
masons, and rock climbers are at particular The patient should be sitting or in a supine risk. Pain and tenderness of the long head of position, the bicipital tendon is identified in the groove, and the point of insertion noted.
presence of rotator cuff tendinosis.
Pharmaceuticals and equipment are listed inTables 1 and 2.16 To inject into the area of thelong head of the biceps tendon, the needle isinserted directly into the most tender area overthe bicipital groove. The needle should enterthe skin at 30 degrees and be directed parallelto the groove (Figure 5). The objective is toinfiltrate the area in and around the grooveand not into the tendon. Intratendinous injec-tion has been associated with rupture. Intra-tendinous needle placement can be appreci-ated by increased resistance to flow of thepharmaceutical. Follow-up care is the same aspreviously described.
The authors indicate that they do not have any con- flicts of interest. Sources of funding: none reported. Shoulder Joint Injection
13. Halverson L, Maas R. Shoulder joint capsule disten- sion (hydroplasty): a case series of patients with 1. Cardone DA, Tallia AF. Joint and soft tissue injec- “frozen shoulders” treated in a primary care office.
tion. Am Fam Physician 2002;66:283-8,290.
2. Winters JC, Jorritsma W, Groenier KH, Sobel JS, 14. Arslan S, Celiker R. Comparison of the efficacy of Meyboom-de Jong B, Arendzen HJ. Treatment of local corticosteroid injection and physical therapy shoulder complaints in general practice: long term for the treatment of adhesive capsulitis. Rheumatol results of a randomised, single blind study compar- ing physiotherapy, manipulation, and cortico- 15. Kelley MJ, Ramsey ML. Osteoarthritis and trau- steroid injection. BMJ 1999;318:1395-6.
matic arthritis of the shoulder. J Hand Ther 3. Dickson J. Shoulder injections in primary care. Prac- 16. Klippel JH, Weyand CM, Wortmann R. Primer on 4. Larson HM, O’Connor FG, Nirschl RP. Shoulder the rheumatic diseases. 11th ed. Atlanta: Arthritis pain: the role of diagnostic injections. Am Fam 17. Patel DR, Nelson TL. Sports injuries in adolescents.
5. Hannafin JA, Chiaia TA. Adhesive capsulitis. A treat- ment approach. Clin Orthop 2000;372:95-109.
18. Mantone JK, Burkhead WZ Jr, Noonan J Jr. Nonop- 6. Bulgen DY, Binder AI, Hazleman BL, Dutton J, erative treatment of rotator cuff tears. Orthop Clin Roberts S. Frozen shoulder: prospective clinical study with an evaluation of three treatment regi- 19. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Efficacy of injections of corticosteroids for sub- 7. Dacre JE, Beeney N, Scott DL. Injections and phys- acromial impingement syndrome. J Bone Joint Surg iotherapy for the painful stiff shoulder. Ann Rheum 20. Morrison DS, Greenbaum BS, Einhorn A. Shoulder 8. de Jong BA, Dahmen R, Hogeweg JA, Marti RK.
impingement. Orthop Clin North Am 2000;31: Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a compar- 21. Hawkins RJ, Kennedy JC. Impingement syndrome ative study of two dose regimens. Clin Rehabil in athletes. Am J Sports Med 1980;8:151-8.
22. Neer CS 2d. Anterior acromioplasty for the 9. van der Windt DA, Koes BW, Deville W, Boeke AJ, chronic impingement syndrome in the shoulder: a de Jong BA, Bouter LM. Effectiveness of corticos- preliminary report. J Bone Joint Surg Am 1972;54: teroid injections versus physiotherapy for treat- ment of painful stiff shoulder in primary care: ran- 23. Andrieu V, Dromer C, Fourcade D, Zabraniecki L, Ginesty E, Marc V, et al. Adhesive capsulitis of the 10. Steinbrocker O, Argyros TG. Frozen shoulder: treat- shoulder: therapeutic contribution of subacromial ment by local injections of depot corticosteroids.
bursography. Rev Rhum Engl Ed 1998;65:771-7.
Arch Phys Med Rehabil 1974;55:209-13.
24. Kerlan RK, Glousman RE. Injections and techniques 11. Woodward TW, Best TM. The painful shoulder: in athletic medicine. Clin Sports Med 1989;8:541- part II. Acute and chronic disorders. Am Fam Physi- 25. Travis RD, Doane R, Burkhead WZ Jr. Tendon rup- 12. Siegel LB, Cohen NJ, Gall EP. Adhesive capsulitis: a tures about the shoulder. Orthop Clin North Am sticky issue. Am Fam Physician 1999;59:1843-52.
Sint-janskruid helpt tegen depressies. Natuurge- neeskundigen wisten dat al langer, maar sinds enkele jaren is ook de reguliere geneeskunde van de werkzaamheid van dit middel overtuigd. Toch houden artsen de boot af. Tekst: Jan van Klinken Doorbraak sint-janskruid als antidepressivum blijft uit “N ee meneer, daar kan ik u niets over zeggen. Het is dat de ‘kruidendokters’