Shoulder Therapeutic Injection

Shoulder
Equipment & Medications

Equipment

9–14 MHz Linear Probe 6–8 MHz Curved (large habitus) 22g 3.5″ Spinal Needle 25g 1.5″ Needle 10 cc Syringe 5 cc Syringe Procedure Tray

Medications

Lidocaine 1% — 10 cc Kenalog 40 mg/cc — 1–2 cc Ropivacaine 0.5% — 3 cc
Procedure Steps
1

Standard pre-procedure workup: obtain consent, confirm indications and contraindications, check allergies, document diabetes history and pain level (0–10).

2

Position patient in lateral decubitus with the contralateral shoulder down and the arm in cross-adduction.

Patient positioning — lateral decubitus Arm in cross-adduction
3

Scan for the posterior glenohumeral joint space. Image at the level of the infraspinatus tendon insertion in longitudinal orientation. Position probe to allow anterior needle approach.

Posterior glenohumeral joint space
Click for annotated view
4

Mark needle entry site and planned injection site on skin.

5

Prep patient with betadine or chlorhexidine × 3. Clear a wide area.

6

Place sterile drape and sterile probe cover.

7

Draw up medications as listed in the equipment list.

8

Place sterile probe on skin, relocate injection site, and inject 1% lidocaine superficially using the 25g 1.5″ needle.

9

Exchange the 25g 1.5″ needle for the 22g 3.5″ spinal needle.

10

Advance needle under ultrasound guidance to the level of the articular cartilage (hypoechoic line).

Needle advancing toward articular cartilage
Click for annotated view

At this point the needle tip is still within the overlying deltoid muscle and not yet at the articular cartilage.

11

Test-inject with 1% lidocaine. Look for fluid accumulation or microbubbles. If there is no resistance and you see joint space distention, proceed. If resistance is felt, spin or slightly retract needle to step off the articular cartilage.

Needle about to enter infraspinatus tendon
Click for annotated view

Needle has been advanced and is about to broach the infraspinatus tendon. Resistance to flow would be expected here — reposition before injecting.

12

Inject 5 cc syringe containing the steroid/ropivacaine mixture. Confirm easy flow throughout injection.

Injectate flow at articular cartilage level
Click for annotated view
13

Document distention of the posterior joint recess with ultrasound.

Posterior joint recess distension
Click for annotated view
14

Clean the area and apply a bandage over the skin entry site.

15

Reassess pain level and provide patient with a pain log.

References

  1. Zwar RB, Read JW, Noakes JB. Sonographically guided glenohumeral joint injection. AJR Am J Roentgenol. 2004;183(1):48–50.
  2. Omer T, Perez M, Berona K, et al. Accuracy of landmark-guided glenohumeral joint injections as assessed by ultrasound in anterior shoulder dislocations. West J Emerg Med. 2021;22(6):1335–1340.
  3. Lin JS, Gimarc DC, Adler RS, et al. Ultrasound-guided musculoskeletal injections. Semin Musculoskelet Radiol. 2021;25(6):769–784.