PROCEDURE: Shoulder Injection
NOTE: THESE PROCEDURES OR INJECTIONS SHOULD ONLY BE ADMINISTERED BY AN MD OR DO TRAINED IN INTERVENTIONAL PAIN MEDICINE
Glenohumeral Joint The glenohumeral joint represents the articulation of the humerus with the glenoid fossa, and it is the most mobile joint in the body. The glenohumeral joint is not a true ball and socket joint. The articulation is stabilized by the soft tissue configurations of a number of ligaments and muscles, including the four muscles of the rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularis) that serve as dynamic stabilizers of the joint. Static stabilizers include the joint capsule, the glenoid labrum, and the glenohumeral ligaments.
INDICATIONS AND DIAGNOSIS: Joint injection in this area should be considered only after other appropriate therapeutic interventions have been tried. These include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and other disease-modifying agents for rheumatoid arthritis. There are three major indications for a glenohumeral joint injection: osteoarthritis, adhesive capsulitis (frozen shoulder), and rheumatoid arthritis.
Osteoarthritis of the shoulder typically occurs in older persons or following traumatic injury in younger persons. Patients usually present with chronic pain, decreased range of motion, and accompanying weakness. Although radiographs can assist in the diagnosis, findings do not always correlate with clinical symptoms or functioning. Adhesive capsulitis is a condition typically occurring in middle-aged and older adults, and it is usually associated with a traumatic injury or nonuse of the shoulder secondary to pain, discomfort, or prolonged immobilization. The condition is more common in women and persons with diabetes.12 There is often accompanying tendinosis or bursitis. Rheumatoid arthritis is a systemic inflammatory disease of autoimmune nature that involves inflammation of the synovium of the shoulder joint. Diagnosis of glenohumeral joint pathology is suspected clinically, and on physical examination, the physician may find painful and decreased range of motion, generalized weakness, and palpable crepitus with shoulder movement.15 Radiographs may be helpful in confirming the diagnosis. Historical factors also cue the diagnosis, with osteoarthritis being more insidious in onset, and rheumatoid arthritis, while chronic in nature, being punctuated by periodic exacerbations secondary to inflammation. In adhesive capsulitis, progressive worsening of pain occurs with loss of motion and a firm, painful end point in the range of motion during physical examination.
TECHNIQUE: The glenohumeral joint can be injected from an anterior, posterior, or superior approach. The anterior and posterior approaches, which are used more often, are described here. In each case, the joint is most easily accessible with the patient sitting, the patient’s arm resting comfortably at the side, and the shoulder externally rotated. Essential landmarks to palpate before performing this injection include the head of the humerus, the coracoid process, and the acromion.
Anterior Approach. The needle (Figure 1) should be placed just medial to the head of the humerus and 1 cm lateral to the coracoid process. The needle is directed posteriorly and slightly superiorly and laterally. If the needle hits against bone, it should be pulled back and redirected at a slightly different angle.
FIGURE 1. (Left) Anterior approach to the glenohumeral joint. (Right) Posterior approach to the glenohumeral joint. Posterior Approach. The needle (Figure 1) should be inserted 2 to 3 cm inferior to the posterolateral corner of the acromion and directed anteriorly in the direction of the coracoid process. As with any injection, aspiration should be done to ensure that there has not been needle placement in the blood vessel. The injection should be performed slowly, but with consistent pressure. Follow-up care should include the following recommendations. Patients should remain seated or placed in supine position for several minutes after the injection. To ascertain whether the pharmaceuticals have been delivered to the appropriate location, the joint or area may be put through passive range of motion. The patient should remain in the office to be monitored for 30 minutes after the injection, and the patient should avoid strenuous activity involving the injected region for at least 48 hours. Patients should be cautioned that they might experience worsening symptoms during the first 24 to 48 hours, related to a possible steroid flare, which can be treated with ice and NSAIDs. A follow-up examination should be arranged within three weeks
What is an Intra-Articular Joint Injection? Injections into joints (ie. hip, shoulder, wrist) are intra-articular injections. If you have a swollen or painful joint your doctor may inject a steroid medication into the joint. Sometimes your doctor may inject a local anesthetic (numbing medicine) along with the steroid.
Why Should I have an intra-articular steroid injection? The steroid injection is given to decrease pain and swelling in the joint.
How long does it take the steroid injection to work and how long will it last? It varies between people; improvement usually starts within 1 to 2 days. If helpful, the injection usually lasts from a few weeks to several months.
What is injected into my joint? The steroid medications are related to cortisone, which is produced by the body itself. The purpose of the injection is to calm down the excessive inflammatory process that may be going on because of injury, excess use, or similar problems. Cortisone injections can also be used for diagnosing some conditions, such as carpal tunnel syndrome, wrist ligament tears, etc. The form of cortisone that I use is called triamcinolone acetonide. It has the longest duration of action and the greatest potency of the cortisones. The most likely side effect is decrease of skin pigmentation in a region about the size of a dime or a quarter. This is not permanent, but may last up to a year.
Are there any side effects? Side effects are very unlikely. Occasionally, the joint is worse for the first 24 hours after the injection. After that the joint normally settles. If the joint becomes more painful after this, please call 718 687 2010 as this could be a sign of infection (a very rare complication). A large number of injections into the same joint may cause damage to the joint.
How do I do it painlessly? I put fast acting numbing medicine in the shot. What is it? Lidocaine (a numbing medicine) that I have specially buffered (made the pH the same as the body’s) to take all of the sting out of it and to speed up how fast it works. The Lidocaine usually is effective in one to two seconds. Amazing, right? This way, you do not feel the long acting numbing medicine or the steroid medicine, which is actually the medicine that does the job.
How many injections can I have? There is no firm limit to the number of injections. However, the effect tends to decrease with repeated injections. There could also be problems from a large number of injections into the same joint.
How often can I have an injection? There is no firm rule about this, but your doctor will want to avoid repeating the injection more often than is necessary.
Do I need to do anything myself after the injection? You should rest the joint after the injection for the first 24-48 hours, especially after the knee or ankle has been injected.