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Diagnostic and therapeutic injection of the shoulder region -- american family physician
Diagnostic 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-
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 1Equipment 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.
TABLE 2Corticosteroid 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-
. 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
. The needle (Figure 1)
the rheumatic diseases. 11th ed. Atlanta: Arthritis Foundation, 1997:420.
should be inserted 2 to 3 cm inferior to the
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
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
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
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
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).
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,
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
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for the treatment of adhesive capsulitis. Rheumatol
results of a randomised, single blind study compar-
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15. Kelley MJ, Ramsey ML. Osteoarthritis and trau-
steroid injection. BMJ 1999;318:1395-6.
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16. Klippel JH, Weyand CM, Wortmann R. Primer on
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