Shoulder Injections What, Where, When, Why and How

Mr Mike Walton BMedSci BMBS MSc FRCS(Tr&Orth) MFSEM(UK)

Consultant Shoulder Surgeon

Shoulder Injections

• Subacromial Bursa

• Glenohumeral Joint

• Acromioclavicular Joint

• Long Head of Biceps Sheath

Why Inject??

• Reduce inflammation

• Treat tendinopathy

• Relieve pain

• Facilitate rehabilitation

Why Inject??

• Reduce inflammation

• Treat tendinopathy

• Relieve pain

• Facilitate rehabilitation

Impingement

• Rotator Cuff Dysfunction

• Impingement

• Compression of Bursa

• Bursitis

• Further Dysfunction

Impingement

• Rotator Cuff Dysfunction

• Impingement

• Compression of Bursa

• Bursitis

• Further Dysfunction

Impingement

• Management needs to break cycle

• Improvement of Cuff Dysfunction through physiotherapy

• Very difficult to engage with rehabilitation if painful

Impingement

• Patients will have

• Night pain

• Mid arc “impingement pain”

• Positive “impingement tests”

• Occasionally unclear

• Diagnostic Injection

Subacromial Injections

• Blind / USS

• Posterior

• or Anterior / Lateral

Subacromial Injections

• Accuracy (Henkus, 2006)

• 76% via the posterior approach,

• 69% via anteromedial approaches .

• 66% correlation between the injector’s confidence in being in the subacromial bursa and accuracy as confirmed on post-injection MRI scanning.  

• accurate injection was associated with good pain reduction

Subacromial Injections

• Accuracy - USS guided

• Naredo et al: RCT of 41 patients between USS guided and blind injections - significant improvement in results at 5 weeks with USS (J Rheumatol 21(2):308-14)

• Chen et al: RCT of 40 patients - no difference in pain or function but was an increased abduction range with USS guided (Am J Phys Med Rehab 85(1):31-5)

Subacromial Injections

• Accuracy - USS guided

• “unable to establish any advantage in terms of pain, function, shoulder range of motion or safety, of ultrasound-guided glucocorticoid injection for shoulder disorders over either landmark-guided or intramuscular injection”

Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev. 2012 Aug 15;8

Subacromial Injections

• Accuracy

• USS guided injections probably more accurate

• USS guided injections possibly more effective

• Evidence limited

• Significant difference in costs / availability

Subacromial Injections• My Practice...

• Vast majority have blind injections

• USS Guided if...

• Large Body Habitus

• “failed injection”

• Uncertain Diagnosis

• Post cuff surgery / decompression

Subacromial Injections

• 1cm below posterolateral corner of the acromion

• Aim anterolateral

• Results are very fast

• Good clinical information

What to Inject?

• The increases in cell proliferation, vascularity and HIF-1α after surgical rotator cuff repair appear consistent with a proliferative healing response, and these features are not seen after glucocorticoid injection

Dean BJ, Franklin SL, Murphy RJ, Javaid MK, Carr AJ. Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: a mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy? Br J Sports Med. 2014 Dec;48(22):1620-6. doi: 10.1136

What to Inject?• Steroids vs Hyaluronans

• Shibata (2001) - RCT Similar results to steroid (JSES 10(3):209-16)

• Blain (2008) - better results with Hyaluronan but no difference between 3 and 5 injections

• Chen (2010) - RCT No difference with placebo at 1 week but improved scores at 6 weeks (JSES 19(4):557-63)

• Penning (2012) - better short-term effect with steroid but no difference at 26 weeks (JBJS Br 21(6):722-7)

What to Inject?• Steroids vs Hyaluronans

• Shibata (2001) - RCT Similar results to steroid (JSES 10(3):209-16)

• Blain (2008) - better results with Hyaluronan but no difference between 3 and 5 injections

• Chen (2010) - RCT No difference with placebo at 1 week but improved scores at 6 weeks (JSES 19(4):557-63)

• Penning (2012) - better effect with short-term steroid but no difference at 26 weeks (JBJS Br 21(6):722-7)

What to Inject

• Hyaluronans

• Cuff tears in the young patient where we are delaying or avoiding repair for a short period

• Theoretical increased risk of infection with steroid

• Small Group

Platelet Rich Plasmas• Very topical

• Good in vitro evidence

• No benefit demonstrated in vivo for shoulder surgery of PRP, L-PRP, PRF or L-PRF

Zumstein MA, Berger S, Schober M, Boileau P, Nyffeler RW, Horn M, Dahinden CA. Leukocyte- and platelet-rich fibrin (L-PRF) for long-term delivery of growth factor in rotator cuff repair: review, preliminary results and future directions. Curr Pharm Biotechnol. 2012 Jun;13(7):1196-206

Chahal J, Van Thiel GS, Mall N, Heard W, Bach BR, Cole BJ, Nicholson GP, Verma NN, Whelan DB, Romeo AA. The role of platelet-rich plasma in arthroscopic rotator cuff repair: a systematic review with quantitative synthesis. Arthroscopy. 2012 Nov;28(11):1718-27.

Platelet Rich Plasmas

• Partial thickness / intratendinous lesions in athletes

Platelet Rich Plasmas

• Partial thickness / intratendinous lesions in athletes

Summary

• Vast majority of patient receive a blind kenalog injection

• 40mL Triamcinolone

• 10mL 0.5% Bupivicaine

• 10-15mL volume

Summary

• Vast majority of patient receive a blind kenalog injection

• 40mL Triamcinolone

• 10mL 0.5% Bupivicaine

• 10-15mL volume

Summary

• USS guided where improved accuracy is essential

• Consider Ostenil in younger patients

Glenohumeral Injections

• 2cm inferior and medial to the posterolateral corner of the acromion

• Aim to coracoid

Glenohumeral Injections

• 1cm lateral and inferior to coracoid

• Aim inferior and medial

• Internally rotate arm

Glenohumeral Injections

• Anterior approach more accurate with “normal” 21G needle.

• Especially in shoulder arthroscopistsKraeutler MJ, Cohen SB, Ciccotti MG, Dodson CC Accuracy of intra-articular injections of the glenohumeral joint through an anterior approach: arthroscopic correlation. J Shoulder Elbow Surg. 2012 Mar;21(3):380-3.

Tong A, Harding R, Graham G. Glenohumeral joint penetration with a 21-gauge standard needle. J Shoulder Elbow Surg. 2012 Dec;21(12):e1-3.

Glenohumeral Injections

• Indications

• Osteoarthritis

• Frozen Shoulder

Osteoarthritis

• Early stages when aiming to delay surgery

• Relatively uncommon

• Corticosteroids

• Unpredictable and short lived

• Possible increased infection risk

Osteoarthritis• Hyaluronans

• As effective as corticosteroids

• Possibly less side effects

• Useful in young patients - 3 injection course

Brander VA, Gomberawalla A, Chambers M, Bowen M, Nuber G. Efficacy and safety of hylan G-F 20 for symptomatic glenohumeral osteoarthritis: a prospective, pilot study. PM R. 2010 Apr;2(4):259-67.

Osteoarthritis

• Hyaluronans

• Kwon (2013) - 300 pts Multicenter double blind RCT saline vs HA: advantage of HA but not significant

• No side-effects

Kwon YW, Eisenberg G, Zuckerman JD. Sodium hyaluronate for the treatment of chronic shoulder pain associated with glenohumeral osteoarthritis: a multicenter, randomized, double-blind, placebo-controlled trial. J Shoulder Elbow Surg. 2013 May;22(5):584-94

Frozen Shoulder

• Corticosteroids

• Short term pain relief

• Limited evidence of long-term efficacy over natural history

• Technically difficult due to tight joint

Frozen Shoulder

• Corticosteroids

• Short term pain relief

• Limited evidence of long-term efficacy over natural history

• Technically VERY difficult due to tight joint

Frozen Shoulder• Quraishi (2007) - better improvement and

faster with hydrodilatation vs MUA (JBJS 89(9):1197-200)

• Yoong (2015) - 86% good or complete resolution of symptoms at 4/12. 91% reduced pain (Skeletal Radiol 44(5)703-8)

• Tveita (2008) - No difference between fluoroscopic hydrodilatation vs steroid injection (BMC Musc Dis 19(9):53)

Frozen Shoulder

Frozen Shoulder• Hydrodilatation

• Wrightington data:

• 76% improved ROM at 3 months

• 91% improved Pain at 1 year

• Especially primary idiopathic frozen shoulder

Acromioclavicular Injections

• ACJ Pain

• OA

• Osteolysis

• Part of “impingement” pathology

• Localised to the joint on palpation

Acromioclavicular Injections

• Direct palpation of ACJ

• Aim medially

• “Walk” into joint

• Max 2ml

Acromioclavicular Injections

• USS more accurate

Borbas P, Kraus T, Clement H, Grechenig S, Weinberg AM, Heidari N. The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers. J Shoulder Elbow Surg. 2012 Dec;21(12):1694-7

Long Head of Biceps

• Bicipital Tendinitis

• Very common source of pain in “impingement syndrome”

• Often source of failure

• Anterior shoulder pain

Long Head of Biceps• Bicipital injections

• Difficult

• Blind in thin patients

• USS much more accurate

• Hyaluronan in young patients - theoretical reduced risk of iatrogenic tendon rupture

Summary

• Injections help pain and facilitate rehabilitation

• USS guidance is more accurate but costly

• Hyaluranon of limited benefit but may be better in young patients

• Best done in clinic as very useful for diagnosis

•Thank you

•Any Questions?

mikewalton@thearmclinic.com

@MrMike Walton

Lennard Funk Shoulder Surgeon

Adam Watts Upper Limb Surgeon

Puneet Monga Shoulder Surgeon

Mike Walton Shoulder Surgeon

Will Tatlow PA to Len Funk

Marie Yates PA to Adam Watts

Debbie Lester PA to Walton & Monga

Linda Hallam Surgical Assistant

Dorothy Chow Practice Admin.

Emma Torrance Research & Outcomes