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Shoulder Injection Techniques

 Shoulder Injection Techniques

Shoulder Injection with corticosteroids and/ or lidocaine is often performed as a part of the treatment of adhesive capsulitis, symptomatic SLAP tears and glenohumeral arthritis.

See Also: Shoulder Range of Motion

Patients with symptoms and functional limitations secondary to rotator cuff tendinopathy, long head of the biceps tendonitis and subdeltoid bursitis unresponsive to oral anti-inflammatory medications and physical therapy are often indicated for subacromial injections.

A number of approaches to the aspiration and injection of the shoulder have been described, with the anterior and posterior approaches most commonly used.

See Also: Shoulder SLAP Lesion

Absolute and Relative Contraindications to Joint Injection

Absolute Contraindications:

  1. Local cellulitis.
  2. Septic arthritis (shoulder aspiration for diagnosis is indicated).
  3. Acute fracture.
  4. Bacteremia.
  5. Joint prosthesis.
  6. History of allergy or anaphylaxis to injectable pharmaceuticals or constituents.

Relative Contraindications

  1. Minimal relief after two previous corticosteroid injections.
  2. Underlying coagulopathy.
  3. Anticoagulation therapy.
  4. Evidence of surrounding joint osteoporosis.
  5. Anatomically inaccessible joints.
  6. Uncontrolled diabetes mellitus.

Posterior Approach for Both Shoulder Injection and Subacromial Injection

Patient is placed in the seated position with their affected upper extremity resting comfortably at their side on the chair’s arm rest with the shoulder in an internally rotated position.

Examine the posterolateral aspect of the shoulder looking for evidence of overlying cellulitis (avoid placing the needle through any area of potential infection).

Palpate the posterior and lateral borders of the acromion process localizing its most posterolateral aspect and palpate the coracoid process anteriorly.

Localize the posterolateral soft spot between the humeral head and the glenoid approximately two fingerbreadths distal and one fingerbreadth medial to the posterolateral corner of the acromion (The location of the humeral head relative to the glenoid can be appreciated with rotation of the upper arm). Mark this site as the starting point for the aspiration/injection. The same starting point has been used for both glenohumeral injection and subacromial injection.

Prep the skin in this region using alcohol and povidone-iodine.

material for shoulder and subacromial injections
Necessary supplies and materials for shoulder injection and aspiration

For shoulder aspiration:

posterior shoulder injection
Both subacromial and shoulder injections are given via the posterolateral portal site which is located two fingerbreadths distal and one fingerbreadth medial to the posterolateral aspect of the acromion process

For shoulder / subacromial injection:

posterior shoulder injection 2
The needle is inserted aiming toward the coracoid process

Anterior Approach for shoulder Injections /Aspirations

Patient is placed in the seated position with their affected upper extremity resting comfortably at their side on the chair’s arm rest with the shoulder in a neutral or slightly externally rotated (approximately 15 to 20°) position.

Examine the anterior aspect of the shoulder looking for evidence of overlying cellulitis (avoid placing the needle through any area of potential infection).

Palpate the coracoid process and the humeral head (rotation of the upper extremity can help localize the humeral head relative to the glenoid).

Mark the starting point for the aspiration/injection just medial to the humeral head, 5 to 10 mm lateral to the tip of the coracoid process.

Prepare the skin in this region using alcohol and povidone-iodine.

anterior shoulder injection
Marking the starting point for shoulder injections (anterior approach)

For shoulder aspiration:

For shoulder injections:

References

  1. Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician. 2002 Jul 15;66(2):283-8. PMID: 12152964.
  2. Courtney P, Doherty M. Joint aspiration and injection and synovial fluid analysis. Best Pract Res Clin Rheumatol. 2009 Apr;23(2):161-92. doi: 10.1016/j.berh.2009.01.003. PMID: 19393565.
  3. Rifat SF, Moeller JL. Injection and aspiration techniques for the primary care physician. Compr Ther. 2002 Winter;28(4):222-9. Review.
  4. Emergency Room Orthopaedic Procedures: An Illustrative Guide for the House Officer Book by Eric J. Strauss and Kenneth A. Egol.

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