Ultrasound guided shoulder injections - The Ultrasound Site

Ultrasound guided injections at the shoulder girdle

Injections around the shoulder girdle are some of the most popular procedures referred for and performed. The rationale for their use is increasingly under scrutiny, and quite rightly in light of some of the potentially negative effects of steroid on tissue. They also are often best performed as part of a comprehensive package of treatment including other approaches.They do however have a role to play for some patients , and some conditions, and we have therefore outlined some of the key techniques which we utilise in our practice. We elaborate on these approaches on our training courses, and through discussions on our social media channels.

Subacromial subdeltoid bursa injection – transverse approach

This technique is similar in its approach to the ‘landmark’ guided approach, but more anterior and not deep to the Acromion process. It is a technique that allows good needle visualisation from the start, and is often comfortable for the patient. If the patient is able to extend the shoulder slightly, it facilitates the humeral head and the greater tuberosity forwards leading to more of the humeral head being exposed, and more of the bursa being visible. Always try and target an area where the bursa is slightly distended to make things easier.

 

Subacromial subdeltoid bursa injection – lateral approach

This can be a helpful alternative technique to have available if the patient is unable to easily extended the shoulder. The subacromial subdeltoid bursa has more dependent regions and one of these areas is distal to the grater tuberosity. Here, a characteristic ‘tear drop’ sign can often be found where the bursa is more distended. You could use this approach if there is distension but also if the patient is more anxious, and are better in lying – this is easily accessible with the patient in supine.

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Acromioclavicular joint injection

This is often a technique that appears straightforward but can be deceptively difficult, highlighted by the poor accuracy rates highlighted in research with regards to landmark guided approaches. The capsule of the joint can sometimes be very thick and difficult to inject into, particularly in degenerative conditions. The lateral approach is the standard approach performed, and can be facilitated by the use of sterile gel to help guide the needle if the shoulder is very slim. Other approaches included a posterior approach, and we cover this on some of our training courses.

Glenohumeral joint injection – posterior medial to lateral approach

We would recommend this technique as a starting point to performing ultrasound guided glenohumeral joint injections. The technique can be performed with the patient in sitting (and the arm horizontally adducted) or in lying. It particularly lends itself to situations where there may be a joint effusion within the posterior recess, for example in degenerative joint conditions. Taking care to avoid the posterior labrum, and ensuring that the needle chosen is long enough to reach the target – it can be deceptively deep!

Glenohumeral joint injection – anterolateral approach

This is a technically more demanding approach to the shoulder, and we would only recommend using this technique once you have mastered needle visualisation and obtaining the correct angles of entry. This technique lends itself to patients where there is not an effusion, and also has an advantage in that there is less depth prior to reaching the target. It can be challenging to always clearly visualise the entire needle with this technique.

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