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ALFRED F.TALLIA, D.O., C.A.Q.S.M. and DENNIS A. CARDONE are professors at the University of Medicine and Dentistry of New Jersey.
Multiple injuries and inflammatory conditions can be found in the shoulder.After other therapeutic interventions have been tried, joint injection should be considered.There are a number of indications for glenohumeral joint injection.Injection may be used for the diagnosis and treatment of osteoarthritis in the acromioclavicular joint.rotator cuff tendinosis, sub-deltoid bursitis, and adhesive capsulitis are some of the conditions that can be treated with subacromial injections.The injections are reserved for inflammation of the bursa.The long head of the biceps has inflammatory conditions that cause persistent pain.Proper technique, choice and quantity of pharmaceuticals are essential for effective outcomes.
The third article in the series covers the shoulder region.The first article in this series covers the rationale, indications, contraindications and general approach to this technique.The shoulder is the site of multiple injuries and inflammatory conditions that lend themselves to diagnostic and therapeutic injection.
The glenohumeral joint is the most mobile joint in the body.The glenohumeral joint is not a ball and sockets joint.The rotator cuff is one of the muscles that serve as stabilizers in the joint.The glenoid labrum is one of the static stabilizers.
After other appropriate therapeutic interventions have been tried, joint injection in this area should only be considered.NSAIDs, physical therapy, and other disease-modifying agents are used for rheumatoid arthritis.There are three major indications for a glenohumeral joint injection.
Osteoarthritis of the shoulder can happen to older people or younger people.Chronic pain, decreased range of motion, and weakness are some of the symptoms that patients present with.It is not always possible to correlate findings with clinical symptoms or functioning.Middle-aged and older adults are more likely to experience a traumatic injury or non use of the shoulder if they have a condition called aadhesive capsulitis.People with diabetes are more likely to have the condition.Rheumatoid arthritis is a disease of inflammation of the shoulder joint.
Radiographs can be used to confirm the diagnosis of glenohumeral joint pathology.There are historical factors that lead to the diagnosis, such as arthritis being more prevalent in the beginning and chronic in nature.A firm, painful end point in the range of motion is what causes the progressive worsening of pain in adhesive capsulitis.
The glenohumeral joint can be injected.The anterior and posterior approaches are used more often.The joint is easiest to access with the patient sitting, the arm resting at the side, and the shoulder rotating.The head of the humerus, the coracoid process, and the acromion are essential landmarks to palpate before performing this injection.
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The needle should be placed just above the head of the humerus and just below the coracoid process.The needle is directed in different ways.If the needle hits against the bone, it should be pulled back.
Anterior approach to the glenohumeral joint.Theterior approach to the glenohumeral joint.
Anterior approach to the glenohumeral joint.Theterior approach to the glenohumeral joint.
The needle should be inserted 2 to 3 cm inferior to the posterolateral corner of the acromion.Aspiration should be done to make sure that there is no needle in the blood vessel.The injection should be done slowly.
The following recommendations should be included in follow-up care.For several minutes after the injection, patients should remain seated or placed in supine position.The passive range of motion can be used to determine if the pharmaceuticals have been delivered to the correct location.The patient should stay in the office for 30 minutes to be monitored and should avoid strenuous activity for at least 48 hours after the injection.During the first 24 to 48 hours, patients should be warned that they might experience worsening symptoms related to a possible steroid flare, which can be treated with ice and NSAID.Within three weeks, a follow-up examination should be arranged.
The AC joint connects the acromion to the clavicle.The joint is not stable because of the weak AC ligament.The major structural support for the joint is provided by the trapezoid and conoid ligaments, otherwise known as the separated shoulder.
Only after a trial of other therapeutic options such as relative rest, activity modification, and NSAID should a therapeutic injection of the AC joint be performed.The AC joint can be injected with osteolysis of the clavicle and osteoarthritis, both of which can cause chronic pain.People who perform repetitive weight training involving the shoulder can cause osteolysis of the clavicle.Osteoarthritis can develop in the AC joint after previous trauma or injury.
History and physical examination can be used to make a diagnosis of osteolysis of the clavicle.Patients with each condition have an onset of pain.There is pain with active or passive adduction of the shoulder on a physical examination.If the patient holds the opposite shoulder and pushes the elbow toward the ceiling against resistance, it will make the pain worse.Radiographs of the AC joint can be used to confirm a diagnosis.
It may be difficult to differentiate pain from AC joint pathology in some cases.Injecting 1 percent lidocaine into the subacromial space to eliminate the source of pain is a useful test.The AC joint is the probable source of pain if it is still present.There will be no relief of symptoms from the injection for patients with osteolysis or arthritis of the AC joint.
The affected arm is placed at the side of the patient in the supine or seated position.A slight depression will be felt at the joint articulation when the clavicle is palpated to the AC joint.Aseptic technique is followed.The needle is inserted from the superior and anterior approach into the AC joint and directed inferiorly.The solution is injected slowly and evenly.The follow-up care for the glenohumeral joint is the same.
The acromion, subdeltoid bursa, coracoacromial, and supra-spinatus tendon are important structures that insert into the greater tuberosity of the humerus.The shape of the acromion affects the subacromial space.As the degree of curve in the acromion increases, the susceptibility to impingement syndrome increases.
After a trial of more conservative therapy, the best treatment plan may be injection at the initial visit.Parsonage-Turner syndrome, a rare disorder of unknown cause that involves chronic shoulder pain, should prompt the physician to consider other causes.
There are four common indications for therapeutic injection in this area.A history of pain in the shoulder and palpation along the acromial border is indicative of a diagnosis of subdeltoid bursitis.
Tendinosis is caused by acute or chronic stress of the rotator cuff.Repeated overhead reaching and weight training can cause rotator cuff tendinosis and impingement.Stress testing the rotator cuff muscles can be used to diagnose tendinosis.There are two tests that can be used for the diagnosis of impingement.The Neer's test elicits pain with a passive abduction of the shoulder to 180 degrees.The acromion process may be seen in cases of impingement.
A subacromial injection can be used to treat capsulitis.The use of a subacromial corticosteroid injection should be combined with physical therapy for most cases of adhesive capsulitis.
It can be hard to distinguish the diagnosis of shoulder pain.Diagnostic injections can be used.Injecting 5 mL of 1 percent lidocaine into the subacromial space can help differentiate rotator cuff tendinosis from other shoulder disorders.Patients with tendinosis or impingement will have temporary relief of symptoms and increased range of motion and strength after the injection.
The acromion's edges are palpated.The acromion is listed in Tables 1 and 2.16, but the needle is just inferior to the posterolateral edge.The needle goes to the opposite nipple.There should be no resistance to the flow of the pharmaceutical material into the space.The follow-up care is the same.
This isn't a true joint, but it is the position of the scapula on the cage that allows it to move freely.There is a bursa in the inferior border of the scapula.
Injection is performed after a trial of other therapies.This area is the site of inflammation associated with various activities, including throwing, weight lifting, and activities of daily living involving pushing or pulling.It is possible to see crepitus with movement or compression of the scapula against the chest wall if the area is palpated.
The patient is placed in the prone position with the ipsilateral hand on the buttock.The inferior border of the scapula is palpated.A technique is used.The equipment and pharmaceuticals are listed in Tables 1 and 2.16, but the needle is not directed toward the chest wall.The follow-up care is the same.
A site for inflammation with any repetitive motion is where the long head of the biceps tendon travels through the bicipital grooves.Rock climbers, weight lifters, and masons are at risk.In the presence of rotator cuff tendinosis, there can be pain and tenderness in the long head of the biceps tendon.
Only after the patient has failed all conservative treatments should the injection be performed.It's a good idea to avoid repeat injections because of the risk of injury.The rotator cuff should be treated before injection.
Inflammation of the bicipital tendon is an indication of persistent pain.Pain with palpation of the tendon along the bicipital grooves is used to make a diagnosis.A positive Speed's test is the elicitation of pain by the patient with their shoulder flexed to 60 degrees, elbow extended to 150 to 160 degrees and palm supinated.
The patient should be sitting or in a supine position with the bicipital tendon visible in the grooves.The most tender area over the bicipital grooves is where the needle is inserted to inject into the long head of the biceps tendon.The needle should enter the skin at 30 degrees.The goal is to get to the area in and around the grooves.Inflammation has been associated with injections.Increased resistance to flow of the pharmaceutical can be appreciated.The follow-up care is the same.
ALFRED F.TALLIA is an associate professor in the department of family medicine at the University of Medicine and Dentistry of New Jersey.He received a degree in public health from Rutgers University.
The director of sports medicine at the Robert Wood Johnson Medical School is Dennis A. Cardone, D.O., C.A.Q.S.M.A graduate of the New York College of Osteopathic Medicine, Old Westbury, N.Y., Dr. Cardone completed his residency at the Robert Wood Johnson Medical School Family Medicine Residency.He completed his fellowship in sports medicine.
Address correspondence to Alfred F. Tallia.There is a family medicine department at the University of Medicine and Dentistry of New Jersey.The authors don't have Reprints available.
There are no conflicts of interest for the authors.There were no sources of funding reported.
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Dennis A. Cardone, D.O., C.A.Q.S.M. and Alfred F. Tallia are the authors of this article.
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