Ultrasound-guided shoulder injections

Welcome to our comprehensive guide on ultrasound-guided shoulder injections. This resource is meticulously designed for healthcare professionals seeking detailed insights into various injection techniques for the shoulder region, a complex and highly mobile joint system.

Our tables present an in-depth analysis of several key shoulder structures, including the Glenohumeral Joint (GHJ), Acromioclavicular Joint (ACJ), Subacromial-Subdeltoid Bursa, Biceps Tendon Sheath, Suprascapular Nerve (SSN), Sternoclavicular Joint (SCJ), and Subcoracoid Bursa. Each section delves into the specific anatomy and common pathologies associated with these structures, providing a clear understanding of the clinical scenarios necessitating these injections.

Symptomatology, where applicable, is outlined to aid in clinical diagnosis. The ultrasound imaging findings section is instrumental in guiding practitioners through the visualization process, ensuring precise targeting during injections. Our tables also detail the commonly used injectates, offering a range of therapeutic options from local anesthetics to advanced orthobiologics like PRP (Platelet-Rich Plasma) and bone marrow concentrate.

Indications for each injection are included to assist in clinical decision-making, ensuring that each procedure is not only necessary but also optimally beneficial for the patient. The injection techniques section provides step-by-step procedural guidance, supported by recommendations for appropriate equipment.

This resource is a valuable tool for practitioners aiming to enhance their proficiency in ultrasound-guided shoulder injections, ultimately leading to improved patient outcomes in the management of various shoulder pathologies.

Uncover the nuances of maximum dosage and effective delivery methods tailored to diverse patient needs. Grasp the significance of pH levels in the efficacy of anesthesia in inflamed tissues and learn about the differential sensitivity among nerve fibers that underscores the order of sensation loss.

Shoulder Pain and Disability Index (SPADI)

Anchors	Questionnaire	Score for each Question
Pain scale	1. At its worst? 2. When lying on the involved side? 3. Reaching for something on a high shelf? 4. Touching the back of your neck? 5. Pushing with the involved arm?	‘No pain at all - 0’ to ‘Worst pain imaginable - 10’.
Functional scale	1. Washing your hair? 2. Washing your back? 3. Putting on an undershirt or jumper? 4. Putting on a shirt that buttons down the front? 5. Putting on your pants? 6. Placing an object on a high shelf? 7. Carrying a heavy object of 10 pounds (4.5 kilograms)? 8. Removing something from your back pocket?	‘No difficulty - 0’ to ‘So difficult it required help - 10’.
Interpretation of Scores	1. Total pain score: Sum of pain dimension / 50 x 100 = % 2. Total disability score: Sum of functional dimension / 80 x 100 = % 3. Total SPADI score: Sum of both dimensions / 130 x 100 = %	1. Adjust denominator if questions are unanswered (e.g., 40 for 1 pain question missed). 2. Total score range: 0 (best) to 130 (worst). 3. Minimum Detectable Change (90% confidence) = 13 points.

Various shoulder pathologies:

Area/Structure	Anatomy	Common Pathology	Ultrasound Imaging Findings	Common Injectate	Indications for Injections	Injection Techniques	Equipment
Glenohumeral Joint (GHJ)	1. Diarthrodial joint - Ball and socket synovial joint between scapula and humerus. 2. Stabilized by intrinsic ligaments, joint capsule, glenoid labrum, and dynamically by the rotator cuff group. 3. Highly mobile, compromising stability.	1. Injuries from acute trauma like falls, leading to anterior shoulder dislocation. 2. Repetitive overuse injuries, degenerative changes, rheumatoid arthritis, adhesive capsulitis.	1. Best visualized in long axis using a Linear array ultrasound transducer (axial oblique plane over the posterior aspect of the GHJ). 2. Findings: cortical irregularities, osteophytes, joint effusions, labral tears/degeneration.	1. Diagnostic purposes: Local anesthetics. 2. Therapeutic purposes: Corticosteroids, hyaluronic acid, prolotherapy, and various orthobiologics like platelet-rich plasma (PRP), bone marrow concentrate, and micronized adipose tissue. 3. Capsular distention: A mix of high-volume (20-60 ml) anesthetics and saline, optionally combined with corticosteroids or orthobiologics such as PRP, platelet lysate, or platelet-poor plasma.	1. Pain unresponsive to Conservative management (rest, icing, anti-inflammatories, and physical therapy.) 2. Guided injections more clinically effective and cost-efficient.	1. Posterior Approach: Patient lateral recumbent with elbow flexed and shoulder internally rotated. Needle from lateral to medial in glenohumeral joint space (between posterior glenoid labrum and humeral head). Avoid posterior labrum. 2. Anterior Approach Via Rotator Interval: Patient supine or semi-supine, slightly extended, externally rotated shoulder. Needle introduced into the rotator interval (lateral to medial) targeting the biceps tendon sheath (between coracohumeral ligament and biceps tendon).	1. Needle: 22- to 25-gauge, 2- to 3.5-inch. 2. Injectate: 4–6 mL of local anaesthetic and 1 mL of corticosteroid.
Acromioclavicular Joint (ACJ)	1. Diarthrodial joint with articulation between the distal clavicle and acromion. 2. Stabilized by acromioclavicular, coracoacromial (horizontal stability), and coracoclavicular ligaments (vertical stability). 3. May contain an intraarticular disk.	1. Injuries from direct blows or falls, causing ACJ sprain, dislocations. 2. Common in collision sports, osteoarthritis, osteolysis in athletes.	1. Best visualized in long axis using high-frequency linear array transducer (coronal oblique plane over the anterior/lateral aspect of the ACJ). 2. Up to 3 mm of hypoechoic ACJ capsule distension normal. 3. Pathology: cortical irregularities, joint effusion, ganglion cysts.	1. Local anesthetics (alone for diagnostic purpose), corticosteroids, prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.). 2. Avoid intraligamentous corticosteroids.	1. Persistent pain from ACJ-associated pain generators unresponsive to conventional treatments. 2. Diagnostic purposes if primary pain generator is uncertain.	1. Intra-articular AC joint technique: Patient lateral recumbent or supine. 2. Needle in-plane from lateral to medial, targeting AC joint space (seperarting acromion and clavicle). 3. Accurate needle placement emphasized, avoiding degenerative changes.	1. Needle: 25- to 30 -gauge, 1- to 1.5-inch. 2. Injectate: 0.5–2 mL of local anesthetic and 0.5–1 mL of corticosteroid. (0.5 to 1.5 mL intra-articular, 0.25 to 0.5 mL per joint capsule area, 0.5 to 1 mL per ligament.)
Subacromial-Subdeltoid Bursa (SA-SD)	1. Largest bursa in body, between acromion (superiorly) and Supraspinatous tendon (inferiorly). 2. Extends laterally towards greater tuberosity and medially towards acromioclavicular joint.	1. Subacromial bursitis and subdeltoid bursitis 2. Subacromial impingement, 3. Rotator cuff tendinosis, 4. Adhesive capsulitis. Increased incidence in patients with rheumatoid arthritis and other inflammatory conditions.	1. Best evaluated using high-resolution linear array probe (coronal oblique plane or sagittal plane). 2. Normal bursa thin hypoechoic structure, approx. 1 mm thick. 3. Bursitis: enlargement, fluid distension or soft tissue thickening.	1. Local anesthetics. (alone for diagnostic purpose), corticosteroids, hyaluronic acid, prolotherapy, orthobiologics (PRP, platelet-poor plasma).	1. Confirmed cases of bursitis. 2. Uncertain diagnosis cases for diagnostic purposes.	1. Lateral Approach: Patient seated upright, shoulder adducted, hand in neutral position. 2. Needle from lateral to medial targeting the subacromial bursa space (between deltoid muscle and SS tendon).	1. Needle: 22- to 25-gauge, 1.5- to 2- inch. 2. Injectate: 2 - 5 mL of local anesthetic and 0.5–1.0 mL of corticosteroid.
Biceps Tendon Sheath	1. Long head of biceps tendon originates from supraglenoid tubercle, superior labrum, and joint capsule. 2. Stabilised by coracohumeral ligament, superior glenohumeral ligament, fibers of the supraspinatous and subscapularis tendons. 3. Exits joint through rotator interval, over anterior shoulder in bicipital groove. 4. Serves to depress humeral head, diminishes stress on IGHL (Inferior Glenohumeral Joint)	1. Ruptures (often with rotator cuff tears), partial tears, tenosynovitis, subluxations/dislocations.	1. Tendon visualized within intertubercular groove (Sagittal plane, parallel to long head of biceps tendon fibers). 2. Pathology: fluid encircling the tendon, localized tenosynovitis, effusion from the joint.	1. Local anesthetics (alone for diagnostic purpose),, corticosteroids, prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.). 2. Avoid intratendinous corticosteroids.	1. Pain isolated to biceps tendon region unresponsive to conservative treatment. 2. Accompanying ultrasound findings.	1. Patient supine or lateral decubitus, shoulder externally rotated. 2. Needle in-plane from lateral to medial or distal to proximal. Target pathologic aspect of LHBT.	1. Needle: 23- to 30 -gauge, 1- to 2-inch. 2. Injectate: 0.5–3.0 mL of local anesthetic and 1 mL of corticosteroid.
Suprascapular Nerve (SSN)	1. Mixed nerve with motor and sensory fibers, motor to SS and infraspinatus muscles, sensory to posterior capsule and subacromial space. 2. Mainly formed by cervical nerve roots C5 and C6, sometimes C4 nerve roots. 2. Courses deep to the trapezius muscle, laterally through posterior cervical triangle and finally entering the supraspinous and infraspinous fossa.	1. Neuropathy due to traction or compression from trauma, repetitive movements, or space-occupying lesions. 2. Suprascapular nerve entrapment	1. High-frequency linear array transducer used. 2. Nerve not always visible, depending on equipment quality and patient echogenicity.	1. Local anesthetics (alone for diagnostic purpose),, corticosteroids, prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).	1. Used for postoperative pain control, chronic shoulder pain in conditions like rheumatoid arthritis, osteoarthritis, adhesive capsulitis.	1. Superior approach for injection: Patient lateral recumbent, seated or prone. 2. Needle in-plane from lateral to medial, targeting just superior to the nerve (beneath the transverse ligament in suprascapular notch).	1. Needle: 22- to 25 -gauge, 1.5–3.5-inch. 2. Injectate: 2-4 mL of local anesthetic and 1 mL of corticosteroid.
Sternoclavicular Joint (SCJ)	1. Diarthrodial joint with articulation between manubrium sterni and proximal clavicle. 2. Stabilized by sternoclavicular, costoclavicular, and interclavicular ligaments. 3. Contains an intraarticular disk. 4. Vital structures situated directly posterior.	1. Injuries from direct impact or blow to the shoulder. 2. Sprains, partial/complete ligamentous tears, subluxations, dislocations. 3. Osteoarthritis.	1. Best visualized in long axis using high-frequency linear array transducer (sagittal/coronal oblique plane over the anterior/ medial aspect of the SCJ). 2. Pathology: cortical irregularities, joint instability, effusion with capsular distension.	1. Local anesthetics (alone for diagnostic purpose),, corticosteroids, prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).	1. Persistent pain from SCJ-associated pain generators unresponsive to conventional treatments. 2. Diagnostic purposes if primary pain generator is uncertain.	1. Anatomic sagittal oblique plane over the anterior aspect of the SCJ. 2. Needle Position: In-plane, with the needle introduced from an anteroposterior direction. 3. Target: Anterior SCJ; ensuring that the needle is carefully placed to avoid puncturing the deep capsule and entering the subacromial space.	1. Needle: 25- to 30 -gauge, 1.5- to 2.5 inch. 2. Injectate: 0.5–1 mL of local anesthetic and 0.5–1 mL of corticosteroid.
Subcoracoid Bursa	1. Located anterior to the subscapularis muscle, deep in relation to the coracoid process. 2. Does not communicate with the glenohumeral joint.	1. Subcoracoid bursitis leading to or resulting from subcoracoid impingement. 2. Associated with rotator cuff and interval tears.	1. Best visualized with a high-frequency linear array transducer (coronal, long axis to the subscapularis tendon). 2. Pathologic bursa contains hypoechoic fluid collection.	1. Local anesthetics (alone for diagnostic purpose),, corticosteroids, prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).	1. Suspected anterior shoulder pain due to subcoracoid bursitis or impingement unresponsive to conservative treatments.	Needle in-plane from lateral to medial, targeting bursae superficial to the sub- scapularis tendon	1. Needle: 25-gauge, 1.5–2-inch. 2. Injectate: 1 mL of local anesthetic and 1 mL of corticosteroids.
Rotator Cuff Tendons	1. SS footprint smaller than infraspinatus, triangular shape. 2. Infraspinatus has long tendinous portion, curving anteriorly to middle facet of greater tubercle.	1. Tendinosis, partial-thickness tears (interstitial, articular, bursal-sided), full-thickness tears (incomplete/complete, retracted/non-retracted), calcific tendinopathy.	1. Best visualized with a high-frequency linear array transducer .	1. Local anesthetics (alone for diagnostic purpose),, corticosteroids, prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.). 2. Avoid intratendinous corticosteroids.	Pain unresponsive to conservative management	1. Supraspinatus Tendon: Various patient positions. 2. Needle in-plane from lateral to medial or vice versa. Target pathologic aspect of SS tendon.	1. Needle: 22- to 25 -gauge, 1.5–2.5-inch. 2. Injectate: 1 - 3 mL of local anesthetic and 1 mL of corticosteroids.

0.5 - 1ml of corticosteroids is typically 40 mg of triamcinolone or methylprednisolone

References