Shoulder Injections - Who, When, Why, How? The Arm Clinic - www.thearmclinic.com

1. Shoulder Injections
What,Where,When,Why and How
Mr Mike Walton BMedSci BMBS MSc FRCS(Tr&Orth) MFSEM(UK)
Consultant Shoulder Surgeon

2. Shoulder Injections
• Subacromial Bursa
• Glenohumeral Joint
• Acromioclavicular Joint
• Long Head of Biceps Sheath

3. Why Inject??
• Reduce inflammation
• Treat tendinopathy
• Relieve pain
• Facilitate rehabilitation

4. Why Inject??
• Reduce inflammation
• Treat tendinopathy
• Relieve pain
• Facilitate rehabilitation

5. Impingement
• Rotator Cuff Dysfunction
• Impingement
• Compression of Bursa
• Bursitis
• Further Dysfunction

6. Impingement
• Rotator Cuff Dysfunction
• Impingement
• Compression of Bursa
• Bursitis
• Further Dysfunction

7. Impingement
• Management needs to break cycle
• Improvement of Cuff Dysfunction
through physiotherapy
• Very difficult to engage with
rehabilitation if painful

8. Impingement
• Patients will have
• Night pain
• Mid arc “impingement pain”
• Positive “impingement tests”
• Occasionally unclear
• Diagnostic Injection

9. Subacromial Injections
• Blind / USS
• Posterior
• or Anterior / Lateral

10. 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

11. 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)

12. 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

13. Subacromial Injections
• Accuracy
• USS guided injections probably more accurate
• USS guided injections possibly more effective
• Evidence limited
• Significant difference in costs / availability

14. Subacromial Injections
• My Practice...
• Vast majority have blind injections
• USS Guided if...
• Large Body Habitus
• “failed injection”
• Uncertain Diagnosis
• Post cuff surgery / decompression

15. Subacromial Injections
• 1cm below
posterolateral corner of
the acromion
• Aim anterolateral
• Results are very fast
• Good clinical information

16. 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

17. 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)

18. 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)

19. 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

20. 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.

21. Platelet Rich Plasmas
• Partial thickness /
intratendinous
lesions in athletes

22. Platelet Rich Plasmas
• Partial thickness /
intratendinous
lesions in athletes

23. Summary
• Vast majority of patient
receive a blind kenalog
injection
• 40mL Triamcinolone
• 10mL 0.5% Bupivicaine
• 10-15mL volume

24. Summary
• Vast majority of patient
receive a blind kenalog
injection
• 40mL Triamcinolone
• 10mL 0.5% Bupivicaine
• 10-15mL volume

25. Summary
• USS guided where
improved accuracy is
essential
• Consider Ostenil in
younger patients

26. Glenohumeral Injections
• 2cm inferior and
medial to the
posterolateral corner
of the acromion
• Aim to coracoid

27. Glenohumeral Injections
• 1cm lateral and
inferior to coracoid
• Aim inferior and
medial
• Internally rotate arm

28. Glenohumeral Injections
• Anterior approach more accurate with
“normal” 21G needle.
• Especially in shoulder arthroscopists
Kraeutler 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.

29. Glenohumeral Injections
• Indications
• Osteoarthritis
• Frozen Shoulder

30. Osteoarthritis
• Early stages when aiming to delay surgery
• Relatively uncommon
• Corticosteroids
• Unpredictable and short lived
• Possible increased infection risk

31. Osteoarthritis
• Hyaluronans
• As effective as corticosteroids
• Possibly less side effects
• Useful in young patients - 3 injection
course
BranderVA, 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.

32. 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

33. Frozen Shoulder
• Corticosteroids
• Short term pain relief
• Limited evidence of long-term efficacy
over natural history
• Technically difficult due to tight joint

34. Frozen Shoulder
• Corticosteroids
• Short term pain relief
• Limited evidence of long-term efficacy
over natural history
• TechnicallyVERY difficult due to tight joint

35. 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)

36. Frozen Shoulder

37. Frozen Shoulder
• Hydrodilatation
• Wrightington data:
• 76% improved ROM at 3 months
• 91% improved Pain at 1 year
• Especially primary idiopathic frozen shoulder

38. Acromioclavicular Injections
• ACJ Pain
• OA
• Osteolysis
• Part of “impingement”
pathology
• Localised to the joint on
palpation

39. Acromioclavicular Injections
• Direct palpation of
ACJ
• Aim medially
• “Walk” into joint
• Max 2ml

40. 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

41. Long Head of Biceps
• Bicipital Tendinitis
• Very common source of pain in
“impingement syndrome”
• Often source of failure
• Anterior shoulder pain

42. 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

43. 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

44. •Thank you
•Any Questions?
mikewalton@thearmclinic.com
@MrMike Walton

45. 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