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Phys Med Rehabil Clin N Am 15 (2004) 407446

Shoulder injections for osteoarthritis and other disorders


Todd P. Stitik, MDa,*, Patrick M. Foye, MDa, Jeffrey Fossati, MDb
a

Department of Physical Medicine and Rehabilitation, UMDNJNew Jersey Medical School, Doctors Oce Center, 90 Bergen Street, Suite 3100, Newark, NJ 07103, USA b Northern New Jersey Pain and Rehab Center, 214 State Street, Suite 203, Hackensack, NJ 07601, USA

Shoulder region injection procedures can be benecial in patients with osteoarthritis and other musculoskeletal disorders. These procedures can yield important diagnostic information, especially when identication of the pain generator via physical examination is limited due to pain-related guarding. Injections also can provide good therapeutic benet directly and indirectly by allowing the patient to participate more meaningfully in physical therapy. As discussed in detail later in this article, some injection procedures can be performed in the examination room as part of a routine oce visit, whereas others may require uoroscopic guidance. From the perspective of injection procedures, the shoulder-girdle region can be conceptualized as being divided into anterior, lateral, and posterior regions (Table 1 and Fig. 1). The important structures that can be injected anteriorly are the acromioclavicular (AC) joint, the glenohumeral (GH) joint, the bicipital tendon sheaths, the subacromial bursa, the sternoclavicular (SC) joint, and the subcoracoid bursa. The subacromial space also can be injected using a lateral or posterior approach. Although some sources make the distinction between the subacromial and the subdeltoid bursae, others consider these two bursae to represent one distinct bursal complex, referred to as the subacromial-subdeltoid bursae complex or simply the subacromial bursa [1]. For simplication, this article collectively refers to these two structures as the subacromial bursa. The GH joint; the tendon insertions of the supraspinatus, infraspinatus, and subscapularis muscles; and the suprascapular nerve region can be injected using a posterior approach.

* Corresponding author. E-mail address: stitikto@umdnj.edu (T.P. Stitik). 1047-9651/04/$ - see front matter 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.pmr.2004.01.006

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Table 1 Shoulder-girdle region structures amenable to injection, listed according to relative body region position Relative shoulder-girdle region Anterior Structure Acromioclavicular joint Bicipital tendon sheaths Glenohumeral joint Sternoclavicular joint Subacromial bursa Subscapularis tendon insertion Infraspinatus tendon insertion Subacromial bursa Supraspinatus tendon insertion Teres minor tendon insertion Glenohumeral joint Suprascapular nerve

Lateral/posterolateral

Posterior

Table 1 shows that the GH joint and the subacromial space are distinct structures. There often is confusion, however, between a subacromial injection and a GH joint injection. Some texts do not make the distinction clearly between these two separate structures [2]. In a patient with an intact rotator cuff, the subacromial space and the GH joint are anatomically distinct from one another. An injection can be performed into either structure, and the injectate remains only within one of those structures. In contrast, in a rotator cuff tear, the two spaces no longer are anatomically separated. Appearance of the injected contrast solution within the subacromial space after it has been injected into the GH joint is the basis behind shoulder arthrography when it is used to diagnose a rotator cuff tear [1]. Arthrography was the primary imaging modality for diagnosing rotator cuff tears before the advent of MRI. Specic shoulder region injection procedures are discussed in the subsequent sections. For each procedure, general comments rst are made with an emphasis on indications. These comments are followed by a review of the literature, a discussion of the authors collective experience with the procedure, and a discussion of the most commonly described technique for performing the injection. Specic injections Subacromial region General comments It has been the authors overwhelming collective experience that injections into the subacromial region constitute most shoulder region injection procedures in an outpatient physiatric practice. As noted earlier, subacromial injections should not be confused with true GH joint injections. The subacromial space is a distinct structure from the GH joint. Subacromial injections are performed for diagnostic and therapeutic reasons.

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A
sternoclavicular joint AC joint subacromial space

Glenohumeral joint

Bicipital tendon

Subscapularis tendon insertion

B
subacromial bursa

supraspinatus tendon insertion Infraspinatus tendon insertion teres minor tendon insertion
Fig. 1. (A) Anterior injection sites. (B) Lateral/posterolateral injection sites. (C) Posterior injection sites. AC, acromioclavicular.

Diagnostic subacromial injections can help dierentiate impingement from a rotator cu tear. A typical scenario is a patient who is unable to abduct the shoulder fully. The patients pain may be interfering with the physical examination such that it is dicult to determine if the inability to abduct the shoulder is due to pain or to true weakness from a rotator cu tear. In this setting, a diagnostic subacromial local anesthetic injection can

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C
suprascapular nerve

glenohumeral joint
Fig. 1 (continued )

help to make the distinction immediately by eliminating pain. Specically, if the patient is able essentially to abduct the arm fully after the injection, a large rotator cu tear is excluded. In addition to their use as diagnostic tools, subacromial injections can be used therapeutically as follow-up treatment in patients with positive diagnostic injections and in patients in whom the diagnosis of subacromial (also known as subdeltoid) bursitis or rotator cuff tendinitis is evident just from physical examination. A therapeutic subacromial corticosteroid injection can be extremely effective in diminishing shoulder pain relatively quickly. It can be particularly helpful in patients who otherwise might have difculty participating in any meaningful way in physical therapy due to pain. Ideally the injection should be combined with other aspects of treatment, including avoidance of the inciting activity, oral nonsteroidal anti-inammatory drugs (NSAIDs), and physical therapy. In contrast to their diagnostic and therapeutic benets, excessively repeated subacromial corticosteroid injections are potentially deleterious to the rotator cu tendons, as suggested by a study in rats in which repeat subacromial corticosteroid injections led to fragmentation of collagen bundles and inammatory cell inltration [3]. It is unclear, however, if the ndings of this study translate to humans and what the safe number of subacromial corticosteroid injections is for a given patient. In contrast to this study, which looked at subacromial injections, previous studies have cautioned against direct intratendinous corticosteroid injections in general because they have been associated with complete collagenic disorganization

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and sometimes with persistent tendinous necrosis several weeks after the injection [4,5]. Adhesive capsulitis is another disorder for which subacromial injections sometimes are performed. This disorder does not seem to be a major indication for subacromial injection because most of the literature on corticosteroid injections for adhesive capsulitis pertains to GH joint injections (see later). Literature review A 2003 Cochrane Database Systematic Review was conducted on corticosteroid injections for shoulder pain [6]. Part of the review compared subacromial corticosteroid injections with other interventions (Table 2). The review concluded that for rotator cuff disease, subacromial steroid injections probably have a small benet over placebo with respect to pain and active range of abduction. No benet of subacromial steroid injections over NSAIDs
Table 2 Clinical trials of subacromial injections for rotator cu disease Type of trial Versus placebo Effect on pain Corticosteroid superior Author, year Adebajo, 1990 [9] Petri, 1987 [8] Blair, 1996 [13] Plafki, 2000 [14] Kirkley, 1999 [15] Vecchio 1993 [16] Strobel, 1996 [17] Adebajo, 1990 [9] Petri, 1987 [8] White, 1986 [10] Petri, 1987 [8] Plafki, 2000 [14] Main conclusion Pooled results of these two studies (n = 45) suggest a small benet over placebo at 4 wk for pain and active abduction Some benet over placebo for pain but no dierence in ADLs Some benet over placebo No dierence No dierence Placebo more benecial for pain, but return to work better for corticosteroid Pooled results of these 3 trials (n = 120) suggest no benet with respect to pain, function, and range of abduction at 4 or 6 wk No benet over NSAIDs alone for pain, function, range of abduction, and remission at 4 wk No signicant difference between the two corticosteroid preparations

No dierence

Placebo superior

Versus NSAIDs

(+) NSAIDs versus NSAIDs alone Crystalline versus lipoid corticosteroid

Abbreviations: ADLs, activities of daily living; NSAIDs, nonsteroidal anti-inammatory drugs.

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was shown, however, based on the pooled results of three trials. A previous literature review of 13 controlled studies of subacromial corticosteroid injections for rotator cuff tendinitis published between 1955 and 1993 also suggested that corticosteroid injections are more effective than placebo [7]. In contrast to the Cochrane review, this earlier review suggested superiority of corticosteroid injections over oral NSAIDs, especially for pain associated with rotator cuff tendinitis. This earlier review had referenced only two of the three double-blind, placebo-controlled studies that were analyzed in a Cochrane review [8,9]. The Cochrane review reached a different conclusion when it had pooled the results of one additional study [10]. Calcic tendinitis was not included specically as part of either review because it was believed to represent an entity that is distinct from simple rotator cuff tendinitis. The earlier review and the Cochrane review agreed that many unanswered questions remain, including the optimal injection technique (see later), optimal number of injections, long-term ecacy, and potential deleterious eects. In addition, the question as to whether benet depends on accurate placement of corticosteroid into the subacromial space has yet to be studied specically because no trials to date have compared blind injection with radiographically guided injection with respect to outcome. The question of ecacy as it relates to injection placement was examined in two studies. One study involved a group of general shoulder pain patients (n = 43) who received an anatomically guided (ie, the injection was performed into the subacromial space) steroid injection versus a trigger or tender point injection [11]. This double-blinded study found via an intention-to-treat analysis that the anatomically placed injection group did better than the tender or trigger point group with respect to pain after 1 week. Another study found an 87% injection accuracy using an anterolateral approach as determined by the inclusion of contrast material in the injection solution followed by postimaging radiography in 48 patients [12]. Injection accuracy correlated in a statistically signicant way with continued pain relief at 2 weeks after the corticosteroid injection. In contrast, pain relief 0.5 hour after the injection probably is not a reliable indicator of injection accuracy because the accurately injected patient group and the nonaccurately injected patient group reported nonstatistically signicant differences in pain (P \ 0.05). Authors experience During a prospective study over a 2-year period, the authors personally supervised 90 subacromial injections that were performed by resident physicians as part of a clinical study on teaching injection procedures [18]. In addition to this structured teaching experience, the authors personally have performed and supervised numerous previous and subsequent subacromial injections during their collective 21 years of postresidency experience. It is the consensus among the authors from their teaching study and clinical experience that subacromial corticosteroid injections often provide quick, dramatic pain relief that is, however, sometimes of temporary

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benet. The results seem to be most impressive in terms of the degree of pain relief and long-term duration for patients with severe acute shoulder pain due to exacerbations of chronic calcic tendinitis/bursitis. For other conditions, such as chronic impingement syndrome and partial rotator cuff tears, pain relief often is good but less dramatic and more likely to be transient. The injection seems to be superior to NSAIDs alone, however, because they often provide pain relief in patients who otherwise have failed previous NSAIDs. Subacromial corticosteroid injections are unlikely to result in cure per se, unless they are combined with other treatment, particularly instruction in proper biomechanics to avoid precipitating activities and shoulder positions. The authors occasionally have performed a subacromial corticosteroid injection in patients with adhesive capsulitis in whom they believed that concomitant subacromial bursitis was present and was interfering with patient progress. The authors collective impression is that the injection can provide some temporary symptomatic relief, which might help a patient to perform physical therapy better. Technique The subacromial bursa can be injected using an anterior, lateral, or posterolateral approach. Unless there is a large palpable subacromial bursa eusion, in which case it is easiest to direct the needle into the region where the eusion is felt best, the authors prefer a posterolateral approach (Fig. 2). This approach provides several advantages over the lateral and anterior approaches (Fig. 3).

Fig. 2. Subacromial injectionposterolateral approach. (A) Use of Physicians Desk Reference to open up subacromial space. (B) Palpation of scapular spine angle. (C) Needle insertion site. (D) Anatomic model showing proper needle entry.

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Fig. 2 (continued )

Advantages over the lateral approach. Advantages of the posterolateral approach over the lateral approach include the following: The subacromial space is perhaps widest when approached posterolaterally. During the procedure, the natural reaction of the patient is to shrug his or her arm upward, especially narrowing the space when

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Fig. 3. Subacromial injectionalternative approaches. (A and B) Lateral approach. (C and D) Anterior approach.

approached from a lateral direction because the humeral head rides just under the lateral aspect of the scapula. The posterolateral approach provides a reproducible palpable landmarkthe lateral corner of the scapula. This landmark is especially useful for injections performed on obese or muscular individuals.

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Fig. 3 (continued )

There is potentially a lot of tissue in between the skin surface and the subacromial space in obese or muscular individuals when using a lateral approach. The needle is being directed from a relatively posterior position to a relatively anterior position. This is an advantage because the subacromial bursa is located in a relatively anterior position within the subacromial space under the anterior-inferior acromion. Advantages over the anterior approach. Advantages of the posterolateral approach over the anterior approach include the following: The posterolateral approach best keeps the needle out of the visual eld of the patient. The anterior approach does not allow for the patient to dangle an object (see later) passively from the hand to open up the subacromial space. The anterior approach does not allow for an assistant to pull actively down on the arm of the patient as another means of opening up the subacromial space. Procedure for posterolateral approach. A procedure for injecting the subacromial space via a posterolateral approach is as follows: Palpate the posterolateral corner of the acromion, and mark the injection site approximately one ngerbreadth below that site, using the plastic cap covering the needle tip. To open up the subacromial space, have the patient dangle a relatively heavy object from the hand, such as the Physicians Desk Reference (see Fig. 2) [19]. Alternatively, an assistant can apply gentle steady traction to the arm. After preparing the skin, insert the needle through the mark, and angle the needle slightly upward and anteriorly. It is important to use a long enough needle and to direct the needle anteriorly enough because the subacromial bursa lies anteriorly within the subacromial space under the undersurface of the anterior-inferior acromion. The goal is to place the needle within the bursa, rather than in the posterior subcutaneous tissue.

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As you advance the needle, you should not encounter any bone resistance. If you do, the needle may be too inferior and contacting the humeral head or too superior and contacting the undersurface of the acromion. You should be able to push the needle upward and feel that it is riding under the undersurface of the acromion. It is important to position the needle as superiorly as possible to avoid the substance of the rotator cuff, which lies underneath the bursa. When you feel this, either attempt to aspirate, if it is indicated, or perform the injection. It has been written that in calcic bursitis, it may be possible to aspirate out calcium deposits from the bursa, but none of the authors has ever been able to do this. If resistance is encountered, try retracting the needle so that it is slightly less medial. If the resistance does not diminish, try advancing the needle in a little further.

Acromioclavicular joint General comments In the authors collective experience, the AC joint is the second most frequently injected structure in the shoulder region. Many pathologic processes, most commonly primary and post-traumatic osteoarthritis, traumatic sprains, and osteolysis of the distal clavicle, may aect this joint. Although this structure is a potential pain generator, particularly in osteoarthritis patients, it can be dicult to make this determination reliably based on history, physical examination, and imaging without performing a diagnostic injection for the following reasons: Asymptomatic AC joint degeneration is frequent and does not always correlate with the presence of symptoms [20]. AC joint and subacromial region pathology often coexist. AC joint pathology is believed to accompany chronic rotator cuff impingement syndrome frequently [21]. It can be almost impossible to apportion the pain between the two structures without a diagnostic injection. The AC joint sometimes is overlooked as a site of potential pathology because of its unique radiographic features. To visualize the joint properly, apical lordotic views are ideal. The AC joint also is atypical in that it is one of the few body regions where erosions, rather than osteophytes typically develop in osteoarthritis. Radiographic evidence of typical osteoarthritis may be lacking on plain lms. Finally, to visualize subtle AC joint separations, weight-bearing stress views are needed. For all of these reasons, routine shoulder x-rays are likely to miss AC joint pathology. The physiatrist sometimes is faced with a patient who has normal routine shoulder lms but pain of possible AC joint etiology.

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There are several different potential pain referral patterns from the AC joint, as was shown in a saline injection study [22]. From a therapeutic perspective, there are no specic exercise principles that address the AC joint per se. Therapeutic AC joint injections play a potentially large role in the management of AC joint pathology. Literature review A PubMed literature search of therapeutic AC joint injections uncovered only one study [23]. Jacob and Sallay [23] retrospectively studied 31 patients with isolated AC joint arthropathy who had received therapeutic injections via a standardized, nonuoroscopically controlled technique and were followed for 2 years. Using an American Shoulder and Elbow Surgeons pain questionnaire and the surgical end point of distal clavicle excision, the study concluded that injecting local corticosteroids into the AC joint may provide short-term pain relief, but does not alter the natural progression of disease. Authors experience The authors have found AC joint injections to be useful in terms of diagnostic information and therapeutic benet. Specically the injection procedure has helped signicantly in conrming that the AC joint was a pain generator in patients in whom the imaging was negative. The injections also have helped patients who have received only partial benet from subacromial corticosteroid injections. In retrospect, these patients also apparently had pathology in the AC joint. The authors have found that uoroscopy is useful in some patients in whom landmark palpation is dicult. Technique Most texts describe an AC joint injection approach that directs the needle perpendicular to the surface of the top of the shoulder. Although patients can be placed in the supine or seated position with the aected arm resting comfortably at their side, the authors collectively prefer that patients be seated. The authors believe that this position facilitates identication of joint line because gravity tends to depress the acromion slightly relative to the clavicle. The joint line can be identied by palpating the clavicle distally to its termination, at which point a slight depression should be felt at the joint articulation. The needle is inserted from the superior approach into the AC joint and directed inferiorly. Various methods for guiding AC joint injections have been described, as follows:     No radiographic visualization Fluoroscopic guidance Ultrasound guidance CT guidance [24]

Choice of injection technique is likely to be inuenced by several factors. The patients body habitus directly aects the ability to palpate the joint.

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Another factor is the availability of uoroscopy or other radiographic imaging modalities. Rates of 67% injection accuracy for blind injections have been reported [25]. There is some controversy, however, as to whether it is necessary actually to inject the joint or whether injection into the tissue over the interosseous groove of the joint at the point of maximal tenderness is adequate [26]. Until studies are performed that show equal efcacy of injections in the area of the AC joint rather than into the AC joint, the authors prefer to make every reasonable attempt to inject into the AC joint. In doing so, it should be kept in mind that there seems to be signicant variability in the anatomy of the AC joint. Slight variations in the relative angle of entry into the joint can make attempts at blindly entering the joint challenging. This is particularly true in the setting of osteoarthritis because the joint can be extremely narrowed. For this reason, the authors often prefer to perform AC joint injections using uoroscopic guidance. The following is an injection protocol used by the authors for AC joint injections using uoroscopy (Fig. 4): The patient is seated, and the c-arm is angled to provide an anteroposterior, slightly lordotic view at approximately 10 of a cephalad tilt. This

Fig. 4. Acromioclavicular joint injections. (A) Use of weight to open up space. (B) Use of metallic clamp to identify joint. (C) Acromioclavicular joint arthrogram. (D) Axillary view to help conrm anteroposterior position of needle.

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Fig. 4 (continued )

view helps to visualize the joint optimally by minimizing the appearance of overlying structures. The patients shoulder preferably should be extended slightly (rather than exed or in a neutral position) because shoulder extension can help to separate the acromion slightly from the distal clavicle. Additional separation of the acromion and clavicle can be achieved by passively hanging a weighted object, such as the Physicians Desk Reference or a sandbag, from the patients hand. A metallic marker, such as a clamp, is placed on the shoulder surface to identify the skin overlying the entry site. The overlying skin is marked by depressing it with a plastic needle cap. After preparing the skin, the overlying skin and subcutaneous tissue sometimes are anesthetized with a small amount of 1% lidocaine depending on the body habitus and anxiety level of the patient. Specically, in obese patients in whom there is a signicant amount of tissue between the skin surface and the joint, it might be helpful from a patient comfort perspective to use preinjection local anesthesia. In an extremely anxious patient, it may be of psychological advantage rst to anesthetize the overlying tissue. When doing this, the physician can report to the patient in a comforting way that the area rst will be numbed before the injection is performed. Distortion of the overlying tissue is much less of an issue for uoroscopicguided injections then for blind injections, in which palpation is much more important and may need to be repeated during the procedure.

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This view is used to guide needle placement into the AC joint by visualizing the relative mediolateral needle position. This view also permits an assessment of the relative needle depth, which is important, as the authors have found that the tendency is to insert the needle too deeply such that it penetrates through the inferior joint surface. Optional: When the needle appears to have entered the AC joint as per the AP apical lordotic view, the relative needle position in the coronal plane can be assessed via an axillary view. To shoot this view best, the patient can rest the affected arm on a table with adjustable height and tilt his or her head away from the affected shoulder as much as possible so as to remove the skull from the line of view of the uoroscope. The resultant image can be difcult to interpret by a physician who is new to this procedure. A useful way of learning how to interpret this image is to instill a small amount of contrast material, which outlines the joint if the needle is placed properly. Through repetition, the physician should become adept at spotting the AC joint line without the need for contrast injection. Because the volume of the joint is small, it probably is preferable to avoid contrast injection unless absolutely necessary. On entering the AC joint, an attempt can be made to aspirate the joint. The authors generally have not been able to aspirate uid from this joint. Aspiration of uid from the AC joint has been described in patients with osteoarthritis [27]. It has been the authors experience that it is the rare exception that uid can be aspirated from the joint, even when uoroscopic guidance has ensured proper needle placement.

Ultrasound has been proposed as an alternative modality for providing joint visualization during aspiration procedures of small joints in general [28]. There are no published studies on the accuracy of ultrasound-guided AC joint injections, and the authors collectively have performed only one AC joint injection procedure under ultrasound before access to uoroscopy was available. It was one authors (T.P.S.) experience that ultrasoundguided injection was more difcult technically to perform compared with uoroscopic-guided AC joint injection. Difculties were encountered with visualizing the needle relative to the joint. A case report of a CT-guided AC joint injection has been published [24]. The authors do not believe that this offers imaging any advantage over uoroscopy, which is generally much more readily available and easier to perform, especially with respect to speed and the personnel needed to operate the imaging equipment. Although the authors have no personal experience with CT-guided AC joint injection procedures, they have found CT guidance to be inconvenient for the limited number of spinal injection procedures that they have performed under CT guidance.

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Glenohumeral joint General comments The GH joint is not a common site of primary osteoarthritis. It can develop secondary osteoarthritis on a post-traumatic basis and due to deposition of calcium hydroxyapatite crystals, in which case the resultant shoulder pathology, including rotator cu degeneration and arthropathy, is known as the Milwaukee shoulder. Because these conditions are not common, injections into the GH joint rarely are performed for either primary or secondary osteoarthritis. In contrast, GH joint injections are performed more frequently as part of treatment for adhesive capsulitis. Literature review There is a moderately large body of literature, relative to other types of shoulder injections, on GH joint corticosteroid injections for adhesive capsulitis. This treatment has been compared alone and in various combinations with placebo, no treatment, and other treatments. Studies that were thought to be of enough scientic merit to warrant inclusion in a Cochrane Database of Systematic Reviews are shown in Table 3 [6]. Table 3 categorizes the studies to compare GH joint corticosteroid injections with other interventions. In most of the studies, the patients also were receiving typical additional treatment such as analgesics, NSAIDs, and home exercises, especially range-of-motion exercises. Table 3 illustrates only differences in treatment beyond the above-mentioned usual interventions. This other treatment is labeled as a major intervention. Because some of the studies involved several treatment arms, these studies are referenced more than once in the table. Although denite conclusions are difcult to draw from these studies because of problems with and differences in study design, a few tentative conclusions are suggested, as follows: The addition of GH joint corticosteroid injections, particularly higher doses of corticosteroids administered via an anterior approach, to other treatments probably more quickly improves pain and range of motion in the early stages of the disease process. Because the natural history of adhesive capsulitis is generally good, there probably are no long-term differences among treatment approaches, including no specic treatment at all. Many questions about these injections still need to be addressed regarding patient selection characteristics, timing of the injections, number of corticosteroid injections, and optimal adjuvant treatment in addition to an injection. With respect to the last question, it also would be of interest to study whether combining GH joint and subacromial injections is superior to GH joint injections alone. In patients with intact rotator cus, these two spaces are distinct and as such might require separate injections if there also seems to be a component of rotator cu tendinitis/subacromial bursitis in

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addition to the adhesive capsulitis. Theoretically, injections into both of these structures should be helpful in this setting, but this question has yet to be addressed. In contrast to the use of GH joint injections in adhesive capsulitis, there are only a few studies on their use in rotator cu pathology. One study found no dierence in benet from corticosteroid injections compared with placebo, ultrasound, or acupuncture [40]. There have been several published studies involving intra-articular injections as one of the injection procedures for shoulder pain due to mixed diagnoses [41,42]. It is difcult to draw conclusions from these studies because of the nonuniformity of diagnoses being treated and the combined injection procedures that were performed. Authors experience The authors have a moderate degree of experience with GH joint injections. Before the availability of uoroscopy in the authors practices, these injections were performed in a blinded fashion. Although no complications were noted, and the authors believed that this procedure was relatively easy, their collective opinions have changed now that they perform the procedure with uoroscopic guidance. Specically the authors have a greater appreciation for how dicult it can be to place the needle into the joint, even using uoroscopic guidance. This is particularly true in obese individuals. Technique GH joint injections at least in theory can be performed without uoroscopic guidance. Either an anterior or a posterior approach can be used. There are certain advantages and disadvantages to the approaches. A posterior approach completely avoids the subclavian artery, subclavian vein, and brachial plexus and oers the psychological advantage of hiding the needle completely from the patients eld of view. In contrast, the anterior approach oers the advantage of a more reproducible bone landmark, the coracoid process, to help guide the injection. Posterior approach. The posterior approach is performed as follows (Fig. 5): The patient typically is seated with the arm internally rotated and resting in the lap. Internal rotation of the arm helps to open up the posterior joint line to allow easier needle entry into the joint. The physician chooses and marks a needle entry site that is opposite to the coracoid process anteriorly and is approximately two ngerbreadths below the scapular spine. After the skin is prepared, the physician typically uses a 3.5-inch or longer spinal needle to aim for the coracoid process, which is being palpated with the index nger of the hand other than that being used to drive the needle.

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Table 3 Clinical trials of glenohumeral joint corticosteroid injections for adhesive capsulitis* Type of trial Versus another intervention(s) Other intervention being compared Versus no treatment Author, year Bulgen, 1984 [29] Main conclusion Some early benet in pain and range for injection but little long-term dierence (6 mo) between groups Some early benet in pain and range for injection but little long-term dierence between groups Injection signicantly better for pain, abduction, and overall treatment success At 7 wk, all outcomes favored the injection group; at 13 wk, only the main complaint remained statistically signicant in the injection group; at 26 wk, no outcome dierences; at 1 yr, only the main complaint was slightly better for the injection group Some early benet in pain and range for injection but little long-term dierence between groups No dierence in pain at 2 and 12 wk Improvement not signicantly dierent Improvement not signicantly dierent No dierence in pain or range of motion at 1 wk6 mo No dierence in pain or range of motion at 1 wk6 mo No dierence in pain or range of motion at 1 wk6 mo (continued on next page)

Versus ice

Bulgen, 1984 [29]

Versus analgesics (only) Versus physical therapy

Lee, 1973 [30] van der Windt, 1998 [31]

Bulgen, 1984 [29]

Versus physical therapy and NSAIDs Versus infrared irradiation Versus bicipital tendon sheath injection Versus subacromial lidocaine injection Versus subacromial steroid injection Versus glenohumeral joint lidocaine injection

Arslan, 2001 [32] Lee, 1973 [30] Lee, 1973 [30] Rizk, 1991 [33] Rizk, 1991 [33] Rizk, 1991 [33]

T.P. Stitik et al / Phys Med Rehabil Clin N Am 15 (2004) 407446 Table 3 (continued ) Type of trial Other intervention being compared Versus capsular distention Air distentsion Versus Air and steroid distention Lignoc aine and steroid distentsion Author, year Main conclusion

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Jacobs, 1991 [34]

No group dierence in pain or range of motion improvement at 16 wk Distention group signicantly better for range and analgesic use; trend favored distention group for pain with activity but no dierence for rest pain No dierences in outcome at 4 wk and 3 mo Some early pain and range benet but no long-term dierence No group dierence in pain or range of motion improvement at 16 wk No dierence in range of abduction at 4 months

Gam, 1998 [35]

Versus stellate ganglion block Combined with another major intervention (+) Subacromial injection versus no treatment versus physical therapy (+) Capsular distention Versus capsular distention (+) Manipulation under anesthesia versus manipulation under anesthesia

Williams, 1975 [36] Bulgen, 1984 [29]

Jacobs, 1991 [34] Kivimacki, 2001 [37]

Versus glenohumeral Three high-dose steroid de Jong, 1998 [38] joint injection injections (40 mg triamcinolone) versus three low-dose steroid injections (10 mg triamcinolone) Anterior versus White, posterior approach 1996 [39]

Trend favored higher dose for pain relief at 6 wk but no dierence in function, external rotation, sleep disturbance, or side eects Higher level of injection accuracy with anterior approach

* Listed in order of increasing aggressiveness of the other intervention in the authors opinion. Abbreviation: NSAIDs, nonsteroidal anti-inammatory drugs.

If intermittent uoroscopic guidance is used, the physician can aim for the center of the posterior aspect of the joint. The posterior joint line can be distinguished from the anterior joint line by observing for an increase in width of the joint line as the patients arm is passively internally rotated and a decrease in width as the arm is passively externally rotated. Correct placement can be conrmed with contrast dye. If uoroscopic guidance is not being used, the physician must rely on feel.

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Fig. 5. Glenohumeral joint injection. (A) Internal rotation opening up posterior joint line. (B) Posterior needle entry into joint. (C) Standard anteroposterior approach. (D) Anterosuperior approach.

The authors suggest that the spinal needle be aimed slightly laterally so that it makes contact with the humeral head; then the needle is walked off the humeral head medially into the joint. This is preferable to aiming slightly medially because the needle tip would be more likely to contact the bony glenoid, in which case it could be difcult to walk the needle off laterally into the joint due to the concave posterior surface of the glenoid, or the needle tip could pierce into the cartilaginous glenoid causing potential injury. Another advantage of a slightly lateral trajectory is that it avoids

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the spinoglenoid notch and exiting suprascapular artery and nerve. Aiming the needle slightly lateral also probably is preferable to aiming directly for the joint itself because depth of penetration would be potentially more difcult to judge without use of a bone landmark, such as when the humeral head is used.  Some suggest that if resistance still is encountered, the needle should be angled upward so that it is in the upper recess of the shoulder joint away from the head of the humerus. Anterior approach. Because of the relative proximity of the neurovascular bundle when injecting from an anterior approach, the authors believe that it is best to ensure that the patient is not anticoagulated and has normal platelet function. Patients who are taking warfarin (Coumadin) stop taking the drug in preparation for the injection, or the injection is performed from a posterior approach. In addition, patients stop taking aspirin and aspirincontaining products and are switched from NSAIDs to cyclooxygenase type 2 inhibitors. The procedure is performed as follows: The injection is performed with the patient placed in a supine position with the arm straight and slightly externally rotated so as to open up the anterior joint line. The acromion is palpated, and a skin entry site is marked such that it is approximately 1 inch inferior to the acromion process [43]. After skin preparation, the needle (preferably a 3.5-inch spinal needle) is directed into the joint. If uoroscopic guidance is used, the physician can aim for the center of the anterior aspect of the joint. The target anterior joint line can be distinguished reliably from the posterior joint line by noting a widening with passive shoulder external rotation. Correct placement can be conrmed with contrast dye. If uoroscopic guidance is not being used, the physician must rely on feel. Similar to the posterior approach, the authors suggest that the spinal needle is aimed slightly laterally so that it makes contact with the humeral head; then the needle is walked off the humeral head medially into the joint. The same advantages to a slight lateral approach are true for the anterior approach as they are for the posterior approach. The major advantage of a slightly lateral entry for the anterior approach is the relative position of the neurovascular bundle, which is situated medial and inferior to the joint. Anterosuperior approach. Finally, an anterosuperior approach has been described [44]. This approach was developed based on anatomic dissections. It uses the anterior aspect of the AC joint as a landmark and involves inserting a 21G, 1.5-inch needle inferiorly into the GH joint. When resistance

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is met, the shoulder is passively internally and then externally rotated. If this rotation is accompanied by movement of the needle tip, the needle is retracted slightly and then should be in the proper position. Bicipital tendon sheath General comments The long and short biceps tendon heads rarely are involved in isolation (ie, rarely without other concomitant shoulder pathology). Bicipital tendinitis generally is found along with rotator cu tendinitis/subacromial bursitis as part of a more generalized shoulder impingement syndrome. The biceps tendons usually are impinged beneath the coracoacromial arch [45]. The physician should differentiate between involvement of the long and short heads of the biceps by palpation. The long head of the biceps tendon runs in the bicipital groove after originating on the anterior labrum, whereas the short head originates on the coracoid process. In contrast to palpation, provocative physical examination maneuvers, including Speeds test and Yergasons maneuver, cannot distinguish reliably between the two tendons as the primary pain generator. Identication of the tendon most involved in pain production is essential because this knowledge guides the needle placement during the subsequent injection. Literature review There are no published studies on the ecacy, accuracy, or side eects associated with bicipital tendon sheath injections. A general statement appears throughout the literature that caution should be exercised with tendon sheath injections because inadvertent intratendinous injections have been associated with tendon rupture. Authors experience The authors have some experience in performing bicipital tendon sheath injections. The authors believe that these injections are needed uncommonly in a typical outpatient musculoskeletal practice because bicipital tendinitis most often accompanies subacromial bursitis/rotator cu tendinitis as a secondary pathologic process rather than as the primary pathology. As such, often an injection is performed more logically into the subacromial space because this directly treats the primary pathology and indirectly treats the secondary pathologic process. Technique The provocative maneuvers that generally are performed before the diagnostic injection are Speeds test and Yergasons maneuver. When these have been assessed, the physician can proceed with the diagnostic injection. The choice as to whether to inject the short or the long head tendon sheath of the biceps tendon depends on the site of maximal tenderness. Specically,

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if the site of maximal tenderness is in the region of the bicipital groove, the long head of the biceps tendon is involved. In contrast, if the area of maximal tenderness is in the vicinity of the coracoid process, the short head of the biceps tendon is involved. Long head of biceps tendon. One technique for performing a diagnostic bicipital tendon sheath injection of the long head of the biceps is as follows (Fig. 6): Identify the most tender area over the bicipital groove. To help guide palpation, the bone aspect of the bicipital groove can be palpated along the anterior aspect of the humerus. Alternatively the bicipital tendon itself often can be palpated, particularly in nonobese patients, by sliding an examining nger over the anterior aspect of the shoulder, lateral to the coracoid process, and feeling for a discrete ropelike structure. Insert the 21G or 22G needle at approximately a 30 angle to the skin surface and parallel to the bicipital groove. It is the authors opinion that a larger gauge needle is unnecessarily painful, whereas smaller gauge needles are more likely to lead to inadvertent intratendinous injection because they allow for too-easy passage into tendons with the minimal sensation of increased resistance being encountered during needle advancement.

Fig. 6. (A and B) Bicipital tendon sheath injection.

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Attempt to contact the bicipital tendon itself with the needle tip but not to penetrate deeply into it. One should try to penetrate at least supercially so as not to end with the needle tip resting outside of the tendon sheath because the goal of the injection is to be between the tendon and its sheath. Increased resistance to needle passage is one clue that the needle has entered the tendon, as is the feeling that the needle is passing through strands of tissue bers. When the physician senses that the needle is contacting the bicipital tendon, an attempt should be made to perform the injection gently. Resistance to injection should be encountered. While still applying pressure to the plunger, the needle should be withdrawn at most a few millimeters at a time. A sudden loss of resistance indicates that the needle is between the tendon and the sheath. The needle should be held in place and the injection completed. A hallmark of a successfully placed injection is the absence of localized tissue fullness after the injection, as would occur if the injection is given into the overlying soft tissue rather than into the tendon sheath. Short head of biceps tendon. A tendon sheath injection of the short head of the biceps tendon is similar to the injection for the long head of the biceps. The only major dierence is that palpation is conducted inferior to the coracoid process because the short head of the biceps tendon inserts on the coracoid process. When the most tender spot along this tendon has been identied, the injection is conducted in an essentially identical fashion as for the long head of the biceps tendon. Not all physicians believe that it is essential to perform a bicipital tendon sheath injection for either the long or the short head tendon sheaths [46]. Nicholas and Lennard [46] wrote that it is sufcient to deposit the steroid in immediate proximity to the point of tenderness, rather than within the tendon sheath itself. Although these authors did not specically state this, it is likely that their reasoning is based on the fact that corticosteroids are lipid soluble to the degree that the injectate likely diffuses into the tendon sheath as long as it has been placed in the immediate vicinity of the tendon sheath. No published studies compare this peritendinous sheath injection method with a true tendon sheath injection. Rotator cu tendon insertion injections General comments Depending on the location of pathology, inammation associated with rotator cu tendinoses theoretically can be treated with injections into the rotator cu insertion sites. These procedures at least can be considered in the setting of rotator cu tendinitis or partial tears. These injections are dierent from subacromial injections, in which the injections are performed into the subacromial bursa, and inammation associated with rotator cu

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pathology presumably is treated by relieving the subacromial bursitis that may develop secondarily or by diusion of the corticosteroid through the undersurface of the bursa and onto the underlying rotator cu tendons. From the perspective of injection procedures, supraspinatus pathology perhaps should be considered as being unique compared with pathology of the other rotator cu tendons because the supraspinatus tendon and its insertion site are situated much closer to the subacromial bursa than are the other three rotator cu tendon insertion sites. It seems logical that a subacromial injection procedure would be more likely to help manage supraspinatus-related inammation compared with pathology of the other rotator cu tendons. The main site of pathology of supraspinatus tendinitis is usually in the rotator cu critical zone of relative hypovascularity located 1 cm proximal to (rather than exactly at) its insertion site on the greater tuberosity [47]. It is unclear as to whether injections at the insertion site or into the subacromial bursa best treat the inammation associated with supraspinatus pathology. For supraspinatus tendinitis, although it generally is believed that rotator cuff tendinitis and subacromial bursitis coexist, this injection has the advantage of placing the medication closer to the actual site of primary pathology in patients with rotator cuff tendinitis. This may be only a theoretical advantage because corticosteroid perhaps diffuses out of the subacromial bursa and onto the rotator cuff tendon sheaths anyway; this might explain why patients who seem to have primarily supraspinatus tendinitis seem to respond at least in part to subacromial injections. A supraspinatus tendon insertion injection is more difcult to perform, however, than a subacromial injection. The exact role of this injection procedure compared with the more traditionally used subacromial injection still is unclear. Literature review These injection procedures have been described, but few studies have examined their ecacy and potential complications. Authors experience The authors collectively have limited experience in performing these procedures because they prefer to treat rotator cu tendinitis or partial rotator tears with a subacromial corticosteroid injection as part of the treatment armamentarium. It has been the authors collective experience, however, that most pathology involves the supraspinatus in its critical zone. It is the consensus among the authors that most rotator cu pathology usually is associated with a component of subacromial bursitis and is treated adequately at least in part with a subacromial corticosteroid injection. The authors also prefer subacromial injections because they are easy to perform, and there is an extremely limited body of literature on rotator cu tendon region injections in general compared with subacromial injections. In the rare instances in which there is pathology involving one of the rotator cu

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tendons at a location clearly outside of the subacromial region, a rotator cu tendon insertion injection at least should be considered. Technique Rotator cu tendon insertion injections should be administered under some, but not excessive, resistance. Excessive resistance suggests that the injection was performed inadvertently into the tendon itself. The specic techniques are discussed subsequently (Figs. 7 and 8). Supraspinatus injection Literature review A PubMed literature search found only one published study on supraspinatus injection [48]. Withrington et al [48] compared supraspinatus tendon region injections with placebo in 25 patients with supraspinatus tendinitis. The study found no difference in pain or analgesic consumption at 2 and 8 weeks of follow-up. Technique Waldman [43] described a technique whereby the patient is placed in a supine position. The arm is internally rotated by placing it behind the patients back. This rotation exposes the supraspinatus insertion site along the anterior aspect of the humeral head. The skin overlying a point just below the anterior edge of the acromion is marked and prepared. The needle is advanced perpendicularly through the skin, subcutaneous tissue, and joint capsule until it impinges on bone. The needle is withdrawn slightly, and the injection is completed under slight resistance. Some authors report that a tender area is discovered by the point of the injecting needle [46]. Infraspinatus injection General comments Isolated infraspinatus pathology is relatively rare compared with supraspinatus tendinitis. Infraspinatus tendinitis has been described in certain individuals, however, such as assembly line workers who perform activities that require repetitive adduction and external shoulder rotation, such as installing brake pads [43]. Literature review A search of the medical literature up until the time of this writing failed to reveal any studies on injections into the infraspinatus insertion site. Technique With the patient seated, the insertion site of the infraspinatus tendon on the posterolateral aspect of the humeral head is identied by palpation. The overlying skin is marked and prepared in the usual fashion. Then the needle is advanced perpendicularly through the skin, subcutaneous tissue, and

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Fig. 7. Rotator cu tendon insertion injections. (A and B) Teres minor tendon insertion injection. (C and D) Infraspinatus tendon insertion injection.

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Fig. 8. Rotator cu tendon insertion injections. (A and B) Supraspinatus tendon insertion injection. (C and D) Subscapularis tendon insertion injection.

margins of the deltoid and infraspinatus muscles until it impinges on bone. The needle is withdrawn slightly out of the periosteum of the humerus, and the injection is completed under slight resistance. Subscapularis injection General comments Isolated subscapularis pathology is relatively rare compared with supraspinatus tendinitis. Subscapularis tendinitis has been described, however, in

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Fig. 8 (continued )

individuals such as assembly line workers, who perform activities requiring repetitive adduction and internal shoulder rotation [43]. Literature review A search of the medical literature up until the time of this writing failed to reveal any studies on injections into the subscapularis insertion site. Technique With the patient lying supine, the insertion site of the subscapularis tendon on the lesser tuberosity of the humerus is identied by palpation. Palpation of this site is facilitated by passively externally rotating the humerus (ie, internally rotating the shoulder joint) approximately 45 . The overlying skin is marked and prepared in the usual fashion. The needle is advanced through the skin and subcutaneous tissue until it impinges on bone. The needle is withdrawn slightly out of the periosteum of the humerus, and the injection is completed under slight resistance. Suprascapular nerve block General comments The suprascapular nerve transmits sensation from the GH joint, the shoulder capsule, and the AC joint. A suprascapular nerve block can help to relieve pain from these structures. A tradeo is that this injection produces weakness of the supraspinatus and infraspinatus muscles because the suprascapular nerve innervates these muscles. In contrast, injections of the GH joint and AC joint do not cause secondary weakness of the supraspinatus and infraspinatus muscles the way a suprascapular nerve block does. Although an algorithm for use of this injection has not been published to the authors knowledge, a suprascapular nerve block can be

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considered as a second-line injection procedure that is performed if a GH joint or AC joint injection either was not technically possible or was not successful. A suprascapular nerve block also can be performed to help diagnose and subsequently to treat a patient with suprascapular nerve entrapment. Its use in the setting of patients with recurrent pain despite subacromial injections is unclear and does not seem to make as much sense as for failed GH joint or AC joint injections because the suprascapular nerve does not transmit sensation from the subacromial space. Literature review Suprascapular nerve blocks and infusions have been studied alone and in combination with other procedures to varying degrees in the management of shoulder pain from a variety of disorders, in the prevention of referred shoulder pain after surgery, and as a diagnostic tool in hemiplegic shoulder pain. Painful conditions for which the nerve block and infusions have been used include adhesive capsulitis, osteoarthritis, rheumatoid arthritis, rotator cu tendinitis and tears, acute shoulder dislocation, chronic shoulder pain presumptively from subacromial bursitis, shoulder pain after shoulder surgery, malignancy-associated shoulder pain, and referred shoulder pain. There does not seem to be any consensus in the literature as to the exact indications for this procedure. Suprascapular nerve blocks have shown some promise in limited trials in reducing shoulder pain associated with adhesive capsulitis [49,50]. The use of suprascapular nerve blocks for adhesive capsulitis due to reex sympathetic dystrophy has been described [51]. Suprascapular nerve blocks also have been studied for adhesive capsulitis in combination with stellate ganglion blocks and electroacupuncture [52]. This study found that the 50 patients who received the combination of a suprascapular nerve and stellate ganglion block along with electroacupuncture did signicantly better than the 50 patients who received only electroacupuncture and the 50 patients who underwent only the two nerve block procedures. It was unclear from the aforementioned study if the patients were thought to have adhesive capsulitis in association with reex sympathetic dystrophy as a reason for including a stellate ganglion block. Several small studies have been published on the use of suprascapular nerve blocks for patients with rheumatoid arthritis or osteoarthritis [53,54]. There has only been one large randomized, placebo-controlled trial examining the efcacy of suprascapular nerve block for shoulder pain in arthritis or degenerative disease using pain and disability end points [55]. Shanahan et al [55] conducted a randomized, double-blind, placebocontrolled trial of the efcacy of suprascapular nerve block for shoulder pain in rheumatoid arthritis or degenerative disease of the shoulder in 83 patients (108 shoulders). These investigators found clinically and statistically signicant improvements in all pain scores, all disability scores, and some range-of-movement scores in the shoulders receiving suprascapular

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nerve block compared with the shoulders receiving placebo at weeks 1, 4, and 12. There were no signicant adverse effects in either group. The procedure also has been studied in combination with an axillary nerve block to treat pain associated with osteoarthritis and rheumatoid arthritis [56]. Vecchio et al [57] described the use of this block in rotator cuff tendinitis via a randomized controlled trial. These authors concluded that a steroid/ bupivacaine mixture was temporarily effective in reducing pain in rotator cuff tendinitis and tears, improving range of movement in tendonitis, and was possible in an outpatient setting with little or no complication risk. Case reports were published on the successful use of suprascapular nerve blocks in acute shoulder dislocation [58]. When suprascapular nerve blocks subsequently were compared with intra-articular local anesthetic to relieve pain associated with acute shoulder dislocation, however, they were found to be inferior in terms of efcacy and ease of administration [59]. Comments have been published on the use of suprascapular nerve blocks for malignancy-associated shoulder pain [60]. Suprascapular nerve blocks also have been studied on a limited basis in reducing shoulder pain after nonarthroscopic shoulder surgery. It is believed to be a useful adjunct to general anesthesia and interscalene brachial plexus blocks for short-term postoperative analgesia, but reports have been conicting regarding its benet at 24 hours after surgery [61]. The procedure also has been studied for referred shoulder pain after nonshoulder surgery but has not been found to be eective. Suprascapular nerve block did not prevent shoulder tip pain after laparoscopic surgery [62]. Another trial found that the procedure did not provide pain relief of referred shoulder pain associated with thoracotomy [63]. Chronic shoulder pain presumptively from the subacromial bursa has been alluded to in the literature as a use for suprascapular nerve block [64]. There have been no published studies, however, on its use in this setting. In addition to single injection procedures, continuous suprascapular nerve blocks have been studied on a limited basis for chronic nonmalignant shoulder pain. An initial case report was published on the use of suprascapular nerve block infusion for analgesia in a scapular fracture [65]. A case report subsequently was published on the successful use of continuous suprascapular nerve block for a patient with lung cancer and breakthrough shoulder pain due to scapular involvement [66]. A case report was published on the successful use of continuous suprascapular nerve block in a patient with adhesive capsulitis [67]. A modied technique for continuous suprascapular nerve blocks was described [68]. Using a catheter to block the suprascapular nerve continuously, the efcacy was believed to be high and the complication rate low. In addition to use in treating shoulder pain, suprascapular nerve blocks were used in a study of painful shoulder in hemiplegic patients to help determine the cause of the pain [69]. Using suprascapular nerve conduction studies along with the block procedure, it was concluded that a lesion of the

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suprascapular nerve was not responsible for the painful contracted shoulder of a hemiplegic patient, although such a lesion may exist incidentally. Authors experience The authors have limited experience with suprascapular nerve blocks; this is due in large part to the authors willingness to perform and familiarity with GH joint and AC joint injections. The authors consider suprascapular injections to be second-line procedures because compared with GH joint and AC joint injections, suprascapular nerve blocks are technically more dicult to perform, carry with them potentially greater morbidity, and cause concomitant rotator cu weakness. The authors prefer to use uoroscopic and electromyographic guidance. Suprascapular nerve blocks oer another potentially important treatment tool in the management of shoulder pain. Technique To the authors knowledge, the rst article describing a suprascapular nerve block was published in 1989 [70]. Since that time, several slight variations of this technique for suprascapular nerve blocks have been described [7175]. A PubMed literature search revealed only one study that compared the different injection techniques. Specically a suprascapular nerve block technique using electromyography to localize the needle (also called near-nerve electromyography technique) was compared with a landmark-guided technique in patients with adhesive capsulitis [76]. The nearnerve electromyography technique was believed to be more successful in providing and maintaining pain relief for the 60-minute study period. A suprascapular nerve block can be performed as follows (Fig. 9): The patient is seated with the arms at the side. The scapular spine is palpated, and the vertebral and acromial ends are marked. A line is drawn to connect these two points, and this line is bisected. The bisection point and the acromial end of the scapular spine are bisected. A small amount (eg, 1 mL) of 1% lidocaine is injected into the soft tissue located 1.5 cm anterior to scapular spine, using a 30G needle. A 25G, 1.5-inch needle is inserted and advanced until the patient reports paresthesias radiating to the shoulder consistent with good needle positioning or the needle contacts bone. If the needle contacts bone, it is withdrawn approximately half of the way out and redirected medially or laterally until paresthesias are reported. Alternatively, if a nerve stimulatoradapted needle is used, needle placement is conrmed by movement of the supraspinatus and infraspinatus muscles in response to electrical stimuli [26].

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Fig. 9. Suprascapular nerve block. (A) Standard setup for suprascapular nerve block. (B) Skeleton representation of suprascapular nerve block. (C) Alternative approach to suprascapular nerve block.

Different solution volumes and compositions for the subsequent injection have been described as follows: (1) 5-mL solution containing either 1% lidocaine [26] or 1% lidocaine and the equivalent of 25 mg of hydrocortisone [71] or (2) 10 mL of a solution containing 1% lidocaine and 40 mg of methylprednisolone. Epinephrine also has been added to injection solutions, presumably for its vasoconstrictive properties. The authors do not add this to their injection solutions.

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A successfully placed injection is characterized by weakness of the supraspinatus and infraspinatus muscles and resolution of shoulder pain if the pain is originating from the GH joint or the AC joint. When using the above-described technique, several points of caution to keep in mind are as follows: Intraneural injection may result in suprascapular nerve damage but can be safeguarded against by asking the patient about severe pain with injection and promptly repositioning the needle if this is to occur. Hematoma and intravascular injection are possible due to the close proximity of the suprascapular vessels. Pneumothorax is possible if the needle is advanced beyond the scapula and into the pleura. The aforementioned side eects potentially can be avoided using a protocol described by Dangoisse et al [74]. This technique involves introducing the needle parallel to the blade of the scapula (ie, away from the direction of the lung and the suprascapular nerve and vessels) and injecting the solution into the oor of the supraspinous fossa (see Fig. 9C). Dangoisse et al reported that this is an easy and safe technique and does not run the risk of pneumothorax or damage to the suprascapular nerve or vessels, as can occur when the needle is introduced into the supraspinous fossa perpendicular to the blade of the scapula then enters the scapular notch. Although no publications were found using a PubMed literature search on the use of uoroscopic guidance for suprascapular nerve blocks, uoroscopy may add a margin of safety to the procedure. In particular, uoroscopic guidance combined with the injection of contrast dye can help to diminish the possibility of inadvertent intravascular injection. In addition, needle depth relative to the scapula can be assessed better with uoroscopic guidance. The question of whether or not to add corticosteroid to the injection solution was addressed in small study (n = 58 shoulders in 29 patients) of rheumatoid arthritis patients [77]. In this study, the injections were performed with bupivacaine and epinephrine plus methylprednisolone compared with bupivacaine and epinephrine. Although signicant improvements were noted in measures of pain, stiffness, and range of most movements for both treatments (3 months) compared with baseline, the results favored bupivacaine and epinephrine. The study authors concluded that the addition of methylprednisolone to the mixture conferred no benet in these patients. Sternoclavicular joint injection General comments The SC joint is formed by the sternal end of the clavicle, the manubrium of the sternum, and the cartilage of the rst rib. It is a true synovial joint

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that contains a meniscus and is covered by a loose brous capsule that is reinforced by the anterior and posterior SC ligaments. The SC joint acts as a fulcrum for all motions of the shoulder girdle [71]. Despite relative excess use over a lifetime, the SC joint usually is only a late and relatively mild site of osteoarthritic involvement [78]. Although osteoarthritis is the most common disorder of the SC joint, the osteoarthritic SC joint also generally does not cause signicant functional impairment [79]. Other pathologic conditions that might necessitate injections or aspiration of the SC joint have been described. Traumatic SC joint dislocations can occur but are relatively rare [80]. Case reports of infections of the SC joint have been published [81]. Other miscellaneous conditions of the SC joint include renal failurerelated amyloid deposition and a Charcot joint in a patient with syringomyelia [82,83]. As a result of the relative scarcity of its involvement in pathology, the SC joint is not one of the more commonly injected structures about the shoulder girdle. For patients who do not respond to injections and other conservative treatment of SC osteoarthritis, resection arthroplasty is an option [84]. Literature review There are no published studies on injections of the SC joint. Authors experience The authors do not have a signicant amount of experience with SC joint injection compared with other shoulder region injection procedures. The authors collective impression is that it is a relatively easy injection to perform because the joint is supercial and easy to palpate. Fluoroscopy should not be necessary to perform the injection. The authors have had no complications from the injection procedure to date. Technique The patient can be positioned either lying supine or sitting up (Fig. 10). The joint can be palpated by identifying the joint medial to the end of the clavicle while having the patient protract and retract the shoulder. The needle should be inserted perpendicularly into the joint and the injection performed. One recommendation for the injectate is 1 mL of 0.25% bupivacaine and 40 mg of methylprednisolone using a 25G needle [43]. Care should be taken not to insert the needle too deeply because of the presence of major vessels posterior to the joint. Specically the left common carotid artery and the brachiocephalic vein lie behind the left SC joint. The brachiocephalic artery lies behind the right SC joint. All of these vessels theoretically are susceptible to injury [43].

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Fig. 10. (A and B) Sternoclavicular joint injection.

Summary Shoulder injection procedures are powerful diagnostic and therapeutic tools for the care of patients with osteoarthritis and other pathologic conditions of the shoulder-girdle region. Although questions regarding many of the details of the specic procedures still need to be answered, a modest body of literature is available. The musculoskeletal physiatrist is in a good position to contribute to this knowledge base through further clinical research.

References
[1] Greenspan A, Chapman MW. Orthopedic radiology: a practical approach. 3rd edition. Philadelphia: Lippincott Williams & Wilkins; 1996. p. 2.5. [2] Hazleman BL. The shoulder. In: Rheumatology examination and injection techniques. Philadelphia: WB Saunders; 1992. p. 367. [3] Akpinar S, Hersekli MA, Demirors H, Tandogan RN, Kayaselcuk F. Effects of methylprednisolone and betamethasone injections on the rotator cuff: an experimental study in rats. Adv Ther 2002;19:194201. [4] Kennedy JC, Willis RB. The effects of local steroid injections on tendons: a biomechanical and microscopic correlative study. Am J Sports Med 1976;4:1121.

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[5] Halpern AA, Horowitz BG, Nagel DA. Tendon ruptures associated with corticosteroid therapy. West J Med 1977;127:37882. [6] Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003;1:CD004016. [7] Goupille P, Sibilia J. Local corticosteroid injections in the treatment of rotator cuff tendinitis (except for frozen shoulder and calcic tendinitis). Groupe Rhumatologique Francais de lEpaule (GREP). Clin Exp Rheumatol 1996;14:5616. [8] Petri M, Dobrow R, Neiman R, Whiting-OKeefe Q, Seaman WE. Randomized, doubleblind, placebo-controlled study of the treatment of the painful shoulder. Arthritis Rheum 1987;30:10405. [9] Adebajo AO, Nash P, Hazleman BL. A prospective double blind dummy placebo controlled study comparing triamcinolone hexacetonide injection with oral diclofenac 50 mg TDS in patients with rotator cuff tendinitis. J Rheumatol 1990;17:120710. [10] White RH, Paull DM, Fleming KW. Rotator cuff tendinitis: comparison of subacromial injection of a long acting corticosteroid versus oral indomethacin therapy. J Rheumatol 1986;13:60813. [11] Hollingsworth G, Ellis R, Shattersley T. Comparison of injection techniques for shoulder pain: results of a double blind randomized study. BMJ 1983;287:133941. [12] Esenyel CZ, Esenyel M, Yesiltepe R, et al. The correlation between the accuracy of steroid injections and subsequent shoulder pain and function in subacromial impingement syndrome. Acta Orthop Traumatol Turc 2003;37:415. [13] Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Efcacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am 1996;78: 16859. [14] Plafki C, Steffen R, Willburger RE, Wittenberg RH. Local anaesthetic injection with and without corticosteroids for subacromial impingement syndrome. Int Orthop 2000;24:402. [15] Kirkley A, Litcheld R, Alvarez C, Herbert S, Grifn S. Prospective double blind randomized clinical trial of subacromial injection of betemethasone and xylocaine versus xylocaine alone in rotator cuff tendonosis. J Bone Joint Surg Br 1999;81(Suppl I):107. [16] Vecchio PC, Hazleman BL, King RH. A double-blind trial comparing subacromial methylprednisolone and lignocaine in acute rotator cuff tendinitis. Br J Rheumatol 1993; 32:7435. [17] Strobel G. [Long-term therapeutic effect of different intra-articular injection treatments of the painful shouldereffect on pain, mobility and work capacity]. Rehabilitation (Stuttg) 1996;35:1768. [18] Stitik TP, Foye PM, Nadler SF, Chen B, Choi ES. See one, practice one on an injection model, do one, teach one: should the classic algorithm be changed to include articial body parts for physiatry resident injection training? Am J Phys Med Rehabil 2003;82:2345. [19] Stitik TP, Nadler SF, Foye PM. Text provides traction. Consultant Consultations in Primary Care 1998;38:2008. [20] Shaffer BS. Painful conditions of the acromioclavicular joint. J Am Acad Orthop Surg 1999;7:17688. [21] Gurbuz H, Unalan H, Sarisaltik H, Sekhavat H, Candan L. The role of acromioclavicular arthritis in impingement syndromes. Yonsei Med J 1998;39:97102. [22] Gerber C, Galantay RV, Hersche O. The pattern of pain produced by irritation of the acromioclavicular joint and the subacromial space. J Shoulder Elbow Surg 1998;7: 3525. [23] Jacob AK, Sallay PI. Therapeutic efcacy of corticosteroid injections in the acromioclavicular joint. Biomed Sci Instrum 1997;34:3805. [24] Sopov V, Fuchs D, Bar-Meir E, Groshar D. Stress-induced osteolysis of distal clavicle: imaging patterns and treatment using CT-guided injection. Eur Radiol 2001;11:2702. [25] Partington PF, Broome GH. Diagnostic injection around the shoulder: hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg 1998;7:14750.

444

T.P. Stitik et al / Phys Med Rehabil Clin N Am 15 (2004) 407446

[26] Walsh NE, Rogers JN, Patil JJ. Injection procedures. In: DeLisa JD, Gans BM, editors. Rehabilitation medicine: principles and practice. 3rd edition. Philadelphia: LippincottRaven; 1998. p. 553610. [27] Schweitzer ME, Magbalon MJ, Frieman BG, Ehrlich S, Epstein RE. Acromioclavicular joint uid: determination of clinical signicance with MR imaging. Radiology 1994;192: 2057. [28] Balint PV, Kane D, Hunter J, Mcinnes IB, Field M, Sturrock RD. Ultrasound guided versus conventional joint and soft tissue uid aspiration in rheumatology practice: a pilot study. J Rheumatol 2002;29:220913. [29] Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens. Ann Rheum Dis 1984;43: 35360. [30] Lee M, Haq AM, Wright V, Longton EB. Periarthritis of the shoulder: a controlled trial of physiotherapy. Physiotherapy 1973;59:3125. [31] van der Windt DA, Koes BW, Deville W, Boeke AJ, de Jong BA, Bouter LM. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. BMJ 1998;317:12926. [32] Arslan S, Celiker R. Comparison of the efcacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. Rheumatol Int 2001;21:203. [33] Rizk TE, Pinals RS, Talaiver AS. Corticosteroid injections in adhesive capsulitis: investigation of their value and site. Arch Phys Med Rehabil 1991;72:202. [34] Jacobs LG, Barton MA, Wallace WA, Ferrousis J, Dunn NA, Bossingham DH. Intraarticular distension and steroids in the management of capsulitis of the shoulder. BMJ 1991;302:1498501. [35] Gam AN, Schydlowsky P, Rossel I, Remvig L, Jensen EM. Treatment of frozen shoulder with distension and glucorticoid compared with glucorticoid alone: a randomised controlled trial. Scand J Rheumatol 1998;27:42530. [36] Williams NE, Seifert MH, Cuddigan JH, Wise RA. Treatment of capsulitis of the shoulder. Rheumatol Rehabil 1975;14:236. [37] Kivimacki J, Pohjolainen T. Manipulation under anaesthesia for frozen shoulder with and without steroid injection. Arch Phys Med Rehabil 2001;82:118890. [38] de Jong BA, Dahmen R, Hogeweg JA, Marti RK. Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens. Clin Rehabil 1998;12:2115. [39] White AET, Tuite JD. The accuracy and efcacy of shoulder injections in restrictive capsulitis. J Orthop Rheumatol 1996;9:3740. [40] Berry H, Fernandes L, Bloom B, Clark RJ, Hamilton EB. Clinical study comparing acupuncture, physiotherapy, injection and oral anti-inammatory therapy in shoulder-cuff lesions. Curr Med Res Opin 1980;7:1216. [41] Richardson AT. Ernest Fletcher Lecture. The painful shoulder. Proc R Soc Med 1975;68: 7316. [42] Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom-de Jong B. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study. BMJ 1997;314:13205. [43] Waldman SD. Atlas of pain management injection techniques. Philadelphia: WB Saunders; 2000. [44] Micheo WF, Rodriguez RA, Amy E. Joint and soft-tissue injections of the upper extremity. Phys Med Rehabil Clin N Am 1995;6(4):8367. [45] Patton WC, McCluskey GM 3rd. Biceps tendinitis and subluxation. Clin Sports Med 2001; 20:50529. [46] Nicholas JJ, Lennard TA. Joint and soft tissue injection techniques. In: . In: Braddom RL, editor. Physical medicine and rehabilitation. 2nd edition. Philadelphia: WB Saunders; 2000. p. 498514.

T.P. Stitik et al / Phys Med Rehabil Clin N Am 15 (2004) 407446

445

[47] Rathbun JB, Macnab I. The microvascular pattern of the rotator cuff. J Bone Joint Surg Br 1970;52:54053. [48] Withrington RH, Girgis FL, Seifert MH. A placebo-controlled trial of steroid injections in the treatment of supraspinatus tendonitis. Scand J Rheumatol 1985;14:768. [49] Dahan TH, Fortin L, Pelletier M, Petit M, Vadeboncoeur R, Suissa S. Double blind randomized clinical trial examining the efcacy of bupivacaine suprascapular nerve blocks in frozen shoulder. J Rheumatol 2000;27:14649. [50] Jones DS, Chattopadhyay C. Suprascapular nerve block for the treatment of frozen shoulder in primary care: a randomized trial. Br J Gen Pract 1999;49:3941. [51] Wassef MR. Suprascapular nerve block: a new approach for the management of frozen shoulder. Anaesthesia 1992;47:1204. [52] Lin ML, Huang CT, Lin JG, Tsai SK. A comparison between the pain relief effect of electroacupuncture, regional never block and electroacupuncture plus regional never block in frozen shoulder. Acta Anaesthesiol Sin 1994;32:23742. [53] Emery P, Bowman S, Wedderburn L, Grahame R. Suprascapular nerve block for chronic shoulder pain in rheumatoid arthritis. BMJ 1989;299:107980. [54] Brown DE, James DC, Roy S. Pain relief by suprascapular nerve block in gleno-humeral arthritis. Scand J Rheumatol 1988;17:4115. [55] Shanahan EM, Ahern M, Smith M, Wetherall M, Bresnihan B, FitzGerald O. Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in chronic shoulder pain. Ann Rheum Dis 2003;62:4006. [56] Lewis RN. The use of combined suprascapular and circumex (articular branches) nerve blocks in the management of chronic arthritis of the shoulder joint. Eur J Anaesthesiol 1999;16:3741. [57] Vecchio PC, Adebajo AO, Hazleman BL. Suprascapular nerve block for persistent rotator cuff lesions. J Rheumatol 1993;20:4535. [58] Edeland HG, Stefansson T. Block of the suprascapular nerve in reduction of acute anterior shoulder dislocation: case reports. Acta Anaesthesiol Scand 1973;17:469. [59] Gleeson AP, Graham CA, Jones I, Beggs I, Nutton RW. Comparison of intra-articular lignocaine and a suprascapular nerve block for acute anterior shoulder dislocation. Injury 1997;28:1412. [60] Meyer-Witting M, Foster JM. Suprascapular nerve block in the management of cancer pain. Anaesthesia 1992;47:626. [61] Neal JM, McDonald SB, Larkin KL, Polissar NL. Suprascapular nerve block prolongs analgesia after nonarthroscopic shoulder surgery but does not improve outcome. Anesth Analg 2003;96:9826. [62] Hong JY, Lee IH. Suprascapular nerve block or a piroxicam patch for shoulder tip pain after day case laparoscopic surgery. Eur J Anaesthesiol 2003;20:2348. [63] Tan N, Agnew NM, Scawn ND, Pennefather SH, Chester M, Russell GN. Suprascapular nerve block for ipsilateral shoulder pain after thoracotomy with thoracic epidural analgesia: a double-blind comparison of 0.5% bupivacaine and 0.9% saline. Anesth Analg 2002;94:199202. [64] Carron H. Relieving pain with nerve blocks. Geriatrics 1978;33:4957. [65] Breen TW, Haigh JD. Continuous suprascapular nerve block for analgesia of scapular fracture. Can J Anaesth 1990;37:7868. [66] Mercadante S, Sapio M, Villari P. Suprascapular nerve block by catheter for breakthrough shoulder cancer pain. Reg Anesth 1995;20:3436. [67] Eckert S, Hornburg M, Frey U, Kersten J, Rathgeber J. Frozen shoulderMRI-veried continuous block of suprascapular nerve. Anasthesiol Intensivmed Notfallmed Schmerzther 2001;36:5147. [68] Meier G, Bauereis C, Maurer H. The modied technique of continuous suprascapular nerve block: a safe technique in the treatment of shoulder pain. Anaesthesist 2002;51: 74753.

446

T.P. Stitik et al / Phys Med Rehabil Clin N Am 15 (2004) 407446

[69] Lee KH, Khunadorn F. Painful shoulder in hemiplegic patients: a study of the suprascapular nerve. Arch Phys Med Rehabil 1986;67:81820. [70] Bruns J, Gruber H. Blockade of the suprascapular nerve in shoulder pain. Anasth Intensivther Notfallmed 1989;24:1002. [71] Cailliet R. Shoulder pain. 2nd edition. Philadelphia: FA Davis; 1972. p. 64. [72] Parris WC. Suprascapular nerve block: a safer technique. Anesthesiology 1990;72:5801. [73] Risdall JE, Sharwood-Smith GH. Suprascapular nerve block: new indications and a safer technique. Anaesthesia 1992;47:626. [74] Dangoisse MJ, Wilson DJ, Glynn CJ. MRI and clinical study of an easy and safe technique of suprascapular nerve blockade. Acta Anaesthesiol Belg 1994;45:4954. [75] Fournier R, Haller G, Hoffmeyer P, Gamulin Z. Suprascapular nerve block by a new anterior approach for perioperative analgesia during major scapular surgery in two patients. Reg Anesth Pain Med 2001;26:2889. [76] Karatas GK, Meray J. Suprascapular nerve block for pain relief in adhesive capsulitis: comparison of 2 different techniques. Arch Phys Med Rehabil 2002;83:5937. [77] Gado K, Emery P. Modied suprascapular nerve block with bupivacaine alone effectively controls chronic shoulder pain in patients with rheumatoid arthritis. Ann Rheum Dis 1993; 52:2158. [78] DePalma AF. degenerative changes in the sternoclavicular and acromioclavicular joint in various decades. Springeld (IL): Charles C Thomas; 1957. [79] Le Loet X, Vittecoq O. The sternocostoclavicular joint: normal and abnormal features. Joint Bone Spine 2002;69:1619. [80] Ferrera PC, Wheeling HM. Sternoclavicular joint injuries. Am J Emerg Med 2000;18: 5861. [81] Mousa AM, Muhtaseb SA, Al-Mudallal DS, Marae AA, Habib FM. Brucellar sternoclavicular arthritis, the forgotten complication. Ann Trop Med Parasitol 1988;82: 27581. [82] Zingraff J, Drueke T, Bardin T. Dialysis-related amyloidosis in the sternoclavicular joint. Nephron 1989;52:367. [83] Chidgey LK, Szabo RM, Benson DR. Neuropathic sternoclavicular joint secondary to syringomyelia: a case report. Orthopedics 1988;11:15713. [84] Pingsmann A, Patsalis T, Michiels I. Resection arthroplasty of the sternoclavicular joint for the treatment of primary degenerative sternoclavicular arthritis. J Bone Joint Surg Br 2002;84:5137.

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