ultrasound guided interventional procedures in.13

Ultrasound-Guided Interventional Procedures inPain Medicine

A Review of Anatomy, Sonoanatomy, and Procedures. Part III: Shoulder

Philip W.H. Peng, MBBS, FRCPC* and Peter Cheng, DOÞ

Abstract: Application of ultrasound for musculoskeletal injections isincreasingly popular. The common targets for shoulder injection are thesubacromial subdeltoid bursa, glenohumeral joint, acromioclavicular joint,and the long head of biceps tendon. This review describes and sum-marizes the anatomy and sonoanatomy relevant to the injection of thesestructures. The feasibility, accuracy, and effectiveness of the injectionsinto and around these shoulder structures, as well as the injection tech-niques, are also described in detail.

(Reg Anesth Pain Med 2011;36: 592Y605)

U ltrasound in pain medicine (USPM) is a rapidly evolvingapplied skill that allows both image-guided interventions

and diagnostic applications within the broader subspecialty ofinterventional pain management. In general, the application ofUSPM can be divided into 3 broad categories according to thetarget tissues: peripheral, axial, and musculoskeletal (MSK)structures (Table 1). The applications to the peripheral and axialstructures were reviewed earlier in this journal.1,2 Because of theextensive amount of information available, the current reviewfocuses only on commonly performed interventions directed atvarious shoulder structures, including the subacromial subdel-toid bursa (SASDB), glenohumeral joint (GHJ), acromioclavic-ular joint (ACJ), and the long head of biceps (LHB) tendon. Thefirst objective of this review was to describe and summarize theanatomy and sonoanatomy relevant to these shoulder structures.The second objective was to summarize the feasibility, accuracy,and effectiveness of injections around and into these structures,as well as the injection techniques.

Pain originating from the MSK system is one of the majorglobal causes of disability and one of the most common reasonsfor patients to visit primary and tertiary care practitioners.3Y5

Interventional pain management is an important modality inthe multidisciplinary care of patients with MSK pain, especiallywhen these patients are refractory to the conservative measures.Ultrasound-guided MSK injection is gaining popularity com-pared with the other imaging modalities because of its variousadvantages (Table 2).

The use of ultrasound for MSK examination and injectionis well established. Structured training programs have been de-veloped for radiologists, rheumatologists, orthopedic surgeons,physical medicine and rehabilitation specialists, sports medicinephysicians, and other health care professionals in Europe andNorth America.6Y9 However, the use of MSK ultrasound is stillin its development phase among interventional pain specialists.This review article was devoted to ultrasound-guided MSK in-jections and serves to increase the awareness and understandingof these concepts for practicing clinicians.

METHODSWe performed a literature search of the MEDLINE database

from January 1980 to February 2011 using the search terms‘‘ultrasound,’’ ‘‘ultrasound-guided,’’ ‘‘pain management,’’ anddifferent shoulder structures relevant in this review, such as‘‘subdeltoid bursa,’’ ‘‘subacromial bursa,’’ ‘‘biceps tendons,’’‘‘glenohumeral joint,’’ and ‘‘acromioclavicular joint.’’

ANATOMYThe shoulder is the most common region where ultrasound-

guided MSK injection is applied because it is prone to injuryor attrition. Pain in the shoulder region can originate from var-ious structures in the shoulder girdle, which is composed ofthe scapula, the clavicle, and the proximal humerus, all acting asa single biomechanical unit. From this, 3 joints (glenohumeral,acromioclavicular, and sternoclavicular joints) and 2 glidingplanes (subacromial and scapulothoracic) provide the greatestrange of movement allowable of any joint in the body.10

Glenohumeral JointThe GHJ is a synovial ‘‘ball-and-socket’’ joint composed of

a round humeral head and a relatively small, flat, pear-shapedglenoid fossa. The glenoid cavity is widened and deepened by thepresence of a fibrocartilaginous rim, the glenoid labrum (Fig. 1).Because only one third of the humeral head is covered by theglenoid cavity, and the capsule is lax and thin, it allows theshoulder the widest range of movement of all joints but confersthe shoulders inherent instability, making it susceptible to sub-luxation and dislocation.11Y13

The joint capsule is attached medially to the margin ofthe glenoid cavity extending to the base of the coracoid processand laterally to the anatomic neck of the humerus (Fig. 1). Thesynovial membrane lines the capsule on its deep surface andoverlies the LHB tendon. From there, 3 recesses are formed: thebiceps tendon sheath anteriorly, the subscapularis recess medi-ally, and the axillary pouch inferiorly (Fig. 2). The implication ofthe biceps tendon sheath will be discussed later in the rotator cuffinterval. The stability of the GHJ is maintained by the ligaments,the rotator cuff tendons, and the deltoid muscle. The gleno-humeral ligaments (GHLs) are 3 weak bands of fibrous tissue(superior GHL [SGHL], middle GHL, and inferior GHL) thatstrengthen the front of the capsule. The coracohumeral ligament

REVIEWARTICLE

592 Regional Anesthesia and Pain Medicine & Volume 36, Number 6, November-December 2011

From the *Department of Anesthesia and Pain Management, UniversityHealth Network, University of Toronto, Toronto, Ontario, Canada; and†Department of Anesthesiology, Division of Interventional Pain Manage-ment, Kaiser Permanente Hospital, Riverside, CA.Accepted for publication August 8, 2011.Address correspondence to: Philip W.H. Peng, MBBS, FRCPC, McL 2-405,

Department of Anesthesia, Toronto Western Hospital, 399 Bathurst St,Toronto, Ontario, Canada M5T 2S8 (e-mail: [email protected]).

Dr Peng received equipment support from SonoSite Canada.This study received institutional funding.Copyright * 2011 by American Society of Regional Anesthesia and Pain

MedicineISSN: 1098-7339DOI: 10.1097/AAP.0b013e318231e068

Copyright © 2011 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.

(CHL) is a strong band of fibrous tissue arising from the cora-coid process and inserting onto the greater and lesser tuberositiesto reinforce the capsule (Fig. 1).

Rotator CuffThere are 4 rotator cuff muscles: subscapularis (SSC),

supraspinatus (SS), infraspinatus (IS), and teres minor (TMi)muscles. The rotator cuff is a tight layer of tendons around theGHJ on the anterior (SSC), superior (SS), and posterior (IS andTMi) aspects of the shoulder (Fig. 3).14 It plays an importantrole in stabilizing the humeral head in the shallow glenoidfossa during the movement of the arm.

The SSC muscle originates from the anterior surface of thescapular fossa and converges into a flat and wide tendon thatinserts onto the lesser tuberosity. The superficial fibers of thetendon overlay the bicipital groove and reach the greater tuber-osity, merging with the CHL and transverse humeral ligament.The SS muscle originates from the SS fossa of the scapula,passes beneath the acromion and coracoacromial ligament (CAL),and inserts on the upper facet of the greater tuberosity (Fig. 4A).The IS muscle originates from the IS fossa and converts into awide tendon that inserts on the greater tuberosity just posteriorand inferior to the SS tendon (Fig. 4B). The interface between ISand SS is not well defined because the fibers of both tendonsintertwine, forming a continuum.10 The TMi muscles originatesfrom a narrow strip on the lateral border of the scapula and in-serts onto the most caudal segment of the greater tuberosity, justposterior and inferior to the IS muscle.

Biceps Tendon and Rotator Cuff IntervalThe LHB tendon arises from the supraglenoid tubercle and

the superior labrum. The proximal part of this tendon is intra-articular but extrasynovial.15,16 The tendon travels obliquelyover the anterosuperior aspect of the humeral head and exits thejoint within the bicipital groove, formed by the greater and lessertuberosities on the lateral and medial sides, respectively (Fig. 5A).In the bicipital groove, an extension of the synovial lining of theGHJ invests the LHB tendon down to approximately 3 to 4 cmbeyond the distal end of the groove (Fig. 2). Thus, fluid disten-sion within the sheath usually reflects an underlying GHJ diseaserather than tendon pathology. In the bicipital groove, the LHBtendon is accompanied by the ascending branch of the anteriorcircumflex artery and is covered by the transverse humeral liga-

ment, a weak ligament formed by the superficial fibers of theSSC tendon.

The rotator cuff interval is a triangular space that occupiesthe area between the tendons of SSC and SS and the base of thecoracoid process.17,18 It is roofed by the rotator interval cap-sule, which is principally made up of the CHL (Figs. 3 and 5)19

and contains the tendon of the LHB tendon and the SGHL. Thecombination of the CHL and SGHL has a complex relationshipto the LHB tendon, which act together to prevent the tendonfrom subluxing in the anterior direction.19 The rotator cuff in-terval is a space where the GHJ synovial lining extends aroundthe biceps tendon and where the arthroscope enters the GHJ toavoid damaging the cuff tendons.20,21 Thus, this is an entry sitein which an interventionist can access the GHJ.

Subacromial Subdeltoid BursaThe SASDB, the largest bursa in the body, is located infe-

rior to the acromion, the CAL, and the deltoid muscle. It overliesthe superior aspect of the SS tendon.10,22 It also extends ante-riorly to cover the bicipital groove and medially to the coracoidprocess (subcoracoid bursa). The lateral border may reach ap-proximately 3 cm below the greater tuberosity.23 The main roleof the SASDB is to minimize attrition of the cuff against thecoracoacromial arch (acromion and CAL) and the deltoid mus-cle during movements of the arm.

Acromioclavicular JointThe ACJ is a small synovial joint located between the

concave medial end of the acromion and the convex lateral endof the clavicle. It has a limited range of motion. The articularsurfaces are made up of hyaline cartilage and are separated by awedge-shaped fibrocartilaginous disk either partly or completely(Fig. 6). The capsule of the ACJ is attached to the articularmargins and is reinforced by the superior, inferior, anterior, andposterior acromioclavicular ligaments.24,25 Caudally, it also re-ceives fibers from the CAL, which blends with the undersurfaceof the ACJ. The coracoclavicular ligament, composed of theconoid and trapezoid ligaments, anchors the lateral aspect of theclavicle to the coracoid process (Fig. 1). Because the ACJ slopesinferomedially, resulting in overriding of the clavicle on theacromion, the coracoclavicular ligament plays a crucial role forthe vertical stability of the ACJ.24 The inferior surface of the joint

TABLE 1. Comparison Among 3 Applications of USPM

Peripheral Axial MSK

Target structures Peripheralsoft tissue

Spine Bursa/joint/tendon

Ultrasoundvisualization oftarget structures

Good tomoderate

Poor tomoderate

Good tomoderate

Conventional orexisting techniquefor injection

Mostly blind Image guided Mostlyblind

Level of difficulty* IYII IIYIII I

*The level of difficulty was based on a meeting and survey of thefounding members of USPM Special Interest Group (SIG) in Innsbruck,May 2009. The level of difficulty was appraised based on 4 criteria andwas classified into level I (basic), level II (intermediate), and level III(advanced).

Adapted with permission from usra.ca.

TABLE 2. Comparison of the 3 Common Imaging Modalitiesfor Pain Management Intervention

Fluoroscopy CT Scan Ultrasound

Soft tissue visualization None to poor Excellent GoodRadiation risk +-++* ++ j

Cost† +++-++++ +++++ ++-+++Portability + j ++-+++Infrastructure ++ ++++ j

Real-time guidance + j +Bone imaging Excellent Excellent Poor-goodDeep structures imaging Reliable Reliable Unreliable

*The amount of radiation increases with the use of real-time anddigital subtraction angiography.

†The cost is variable depending on the models and the institutionpricing.

Reprinted with permission from usra.ca.

Regional Anesthesia and Pain Medicine & Volume 36, Number 6, November-December 2011 Ultrasound in Pain Medicine/Shoulder

* 2011 American Society of Regional Anesthesia and Pain Medicine 593


is in direct contact with the subacromial bursa and rotator cuffand may play a role in the development of the impingementsyndrome (Fig. 6).

SONOANATOMY

Biceps Tendon and Rotator Cuff IntervalThe LHB tendon is examined, with the patient sitting with

the arm placed in neutral or slight internal rotation position, theelbow bent, and the palm facing up (Fig. 7A). A high-frequencylinear probe is used. Approximately at the level of coracoidprocess, a short-axis view of the humerus reveals the greater and

lesser tuberosities and the bicipital groove where the LHB ten-don is found. The greater tuberosity has a rounder look, whereasthe lesser tuberosity assumes a pointed shape (Fig. 7A). Tiltingof the probe is important (Fig. 7B), as the echogenicity of thebiceps tendon in this short-axis view is dependent on the angleof the probe position (anisotropy). Doppler imaging of the areareveals the ascending branch of the anterior circumflex artery,which is usually on the lateral side of the tendon. In the bicipitalgroove, the tendon is invested by its synovial sheath, and theeffusion at this level should be noted.

The LHB tendon runs a superomedial course and enters theGHJ through the rotator cuff interval. To obtain a short-axis scan

FIGURE 1. Glenohumeral joint showing various ligaments and the joint capsule. The anterior capsule is reinforced by the superior,middle, and inferior GHL. The insert shows the articular surface, the glenoid process, and the labrum. Reprinted with permissionfrom usra.ca.

FIGURE 2. The drawing of 3 main recesses of the joint (left): (A) the biceps tendon sheath, (B) the axillary pouch, (C) the subscapularrecess, and the corresponding radiographic (arthrogram) appearance (right). Reprinted with permission from usra.ca.

Peng and Cheng Regional Anesthesia and Pain Medicine & Volume 36, Number 6, November-December 2011

594 * 2011 American Society of Regional Anesthesia and Pain Medicine


of the LHB tendon, the orientation of the probe needs to beadjusted accordingly (Fig. 7C). In this interval, the SS and SSCtendons are on the lateral and medial sides, respectively. TheCHL appears as a thick hyperechoic band over the LHB tendon,and the joint capsule is seen as a thin hypoechoic layer arisingfrom the deep edge of the SS tendon and intervening between theligament and the LHB tendon (Fig. 7C). The optimal scan at thislevel is obtained by extension of the arm, which causes maximalopening of the rotator cuff interval, stretches the LHB tendonagainst the humeral head, and tightens the CHL. In the distalportion of the rotator cuff interval, the SGHL and CHL form ananterior sling around the anterior and medial aspects of the LHBtendon, which is responsible for stability of LHB tendon at theentrance of intertubercular groove (Fig. 5).

Supraspinatus Tendon and SubacromialSubdeltoid Bursa

The long-axis view of the SS tendon is obtained with themedial aspect of the probe over the lateral part of the acromion(Fig. 8A). The intraarticular portion of the LHB tendon runsparallel to the SS tendon and can be used as a reference. With thearm in neutral position, only the distal portion of the SS ten-don can be seen as a convex beak-like structure attached to thegreater tuberosity. Dynamic assessment of subacromial impinge-ment can be assessed, with the patient abducting the arm while ininternal rotation. With this maneuver, the SS tendon can be seenpassing deep to the coracoacromial arch.

To visualize the SASDB, a modified Crass position (pa-tient’s arm extended posteriorly with the palm on the superioraspect of the iliac wing) is recommended26,27 to provide a morecomplete visualization of the tendon (Fig. 8B). A high-frequencylinear probe is placed in the long axis of the SS tendon, whichis parallel to the intraarticular portion of the LHB tendon. Withthis scan, the deltoid muscle, SS tendon, and acromion can beseen as well. Under normal circumstances, the synovial lining ofthe SASDB cannot be visualized, but its presence can be esti-mated from the peribursal fat in between the deltoid muscle andSS tendon and the use of dynamic scanning (Fig. 8A).

Glenohumeral JointThe GHJ is best examined on transverse scan by placing the

transducer over the IS tendon. The patient is placed in the sittingor lateral position, with the ipsilateral arm touching the contra-lateral shoulder (Fig. 9A). A linear probe is typically used, withthe exception of patients of very high body mass index, and theprobe is placed in the long axis of the IS tendon caudal to thescapular spine (Fig. 9A). With this probe position, the posteriorpart of the humeral head, glenoid process, and labrum are vi-sualized. Medial to the GHJ, the spinoglenoid notch is usuallyvisualized (Fig. 9B). The suprascapular nerve, accompanied bysuprascapular artery, curves around this notch to supply the ISmuscle in the IS fossa. A paralabral cyst associated with labraltear can be found in this notch.

Acromioclavicular JointThe joint can be simply reviewed with a high-frequency

linear probe over the joint in the coronal plane. The hypoechoic

FIGURE 3. A schematic diagram showing the arrangement of the4 rotator cuff muscles: subscapularis, SS, IS, and TMi. Reprintedwith permission from usra.ca.

FIGURE 4. A, Anterior view of the shoulder showing the subscapularis and SS muscles. The anterior portion of the deltoid muscle wasreflected to show the underlying rotator cuff muscle. B, Posterior view of the shoulder to show the IS and TMi muscle. The posteriorportion of the deltoid muscle was partially removed to show the underlying muscle. Reprinted with permission from usra.ca.




joint space is seen between the hyperechoic ends of the acromionand the distal clavicle, which may not appear at the same level in16% of patients because of the variable obliquity of the joint(Fig. 10).28 In a young healthy patient, a fibrocartilaginous diskis usually seen as a slightly hyperechoic wedge-shaped structureattached to the superior joint capsule and is mobile in its location,depending on the arm position. The superior acromioclavicularligament is a hyperechoic fibrillar structure abutting the bonysurfaces of the joint.

An os acromiale is an accessory bone of the acromion thatderives from the nonfused epiphysis of the anterior part of theacromion. The prevalence is approximately 8% and is bilateral inone third of the cases.29 Although os acromiale is usually anincidental finding during the scanning of ACJ, it can be a po-tential cause for anterosuperior impingement of the SS tendon.Ultrasound scan shows well-defined cortical discontinuity on thesuperior aspect of the acromion, often mimicking a double ACJ.

INJECTION TECHNIQUES FORSPECIFIC JOINT/BURSA

Acromioclavicular Joint

OverviewThe main indication for ACJ injection is osteoarthritis of

this joint.30 The ACJ is a complex gliding synovial joint thatallows 3 types of movement: gliding, hinge-like, and rotationmovement. It is believed that the rotational motion, shear stress,and high compressive force from the surrounding musclescontribute to degenerative process of the joint.31,32 Osteoarthritisof the ACJ is a common source of shoulder pain that is oftenneglected by clinicians and researchers because of the higherprevalence of rotator cuff pathology. The proper diagnosis ofACJ osteoarthritis requires a thorough physical examination,plain-film radiograph, and a diagnostic local anesthetic injec-tion, which has been well reviewed elsewhere.24

EfficacyWhereas the diagnostic role of ACJ injection is widely ac-

cepted,30 the role of steroid injection is less certain. Literaturesearch revealed 4 case series.33Y36 All supported the role of short-term relief following ACJ steroid injection. In a retrospectivecase series, 27 patients with isolated ACJ arthritis received ste-roid injections with landmark-based technique.35 Significantpain relief and function improvement were achieved in 25 of27 patients, with a mean duration of improvement of 20 days(range, 2 hrs to 3 months). In another study, 18 patients withisolated unilateral ACJ arthropathy were prospectively studied2 weeks after the ACJ injections were performed under fluoro-scopic guidance.36 All patients had pain relief at 2 weeks, withmean pain score decrease from 7 of 10 to 3.6 of 10 (range, 2Y10and 0Y8, respectively). The average duration of pain relief was14.3 weeks (range, 8Y24 weeks). Bain et al33 performed ACJsteroid injection in 44 patients with confirmation of needle place-ment with fluoroscopy, and the patients were followed up for an

FIGURE 5. A, The anterosuperior view showing the rotator cuff interval, which is a triangular space between the tendons of subscapularis(anterior) and SS (posterior) muscles and the base of the coracoid process. The roof is the CHL (ghosted) and the contents are theLHB tendon (blue) and SGHL (green). B, The cut-out of the rotator cuff interval to show the content. The SGHL, a focal thickening of theGHJ capsule, runs anterior to the tendon of the LHB initially (position a). The SGHL maintains a close relationship with the LHB tendonand subsequently inserts into a small depression above the lesser tuberosity (position b), contributing to the biceps reflection pulley(position c) to prevent the dislocation of the LHB tendon. Reprinted with permission from usra.ca.

FIGURE 6. The ACJ is a synovial joint with the articular surfacesseparated by a wedge-shaped fibrocartilaginous disk (asterisk).The inferior surface of the joint is in direct contact with thesubacromial bursa and SS muscle and may play a role in thedevelopment of the impingement syndrome. Reprintedwith permission from usra.ca.




average duration of 42 months. Approximately 14% resulted inmore than 3 months of pain relief. Hossain et al34 studied ACJsteroid injections in 25 shoulders from 20 patients in a prospective5-year follow-up. They used the Constant score, which is a com-posite score of pain and function (total score of 100 points with15 points in pain assessment), and found the patients continuedto improve after 6 months. The average Constant score was sig-nificantly better at 5 years than that of preinjection level, withmore than 20 points improvement in 72% of the shoulders inthe final assessment. No randomized controlled study so far hasbeen published to confirm the effectiveness of ACJ injection.

Accuracy of Landmark-Based VersusUltrasound-Guided Techniques

The literature supporting the use of image-guided injec-tion is robust. In cadaveric study where the accuracy of injection

was confirmed with dissection, landmark-based techniques wereonly 40% to 66% accurate, whereas the accuracy was 100% withfluoroscopy guidance.37Y39 In clinical studies where fluoroscopywas used as the validation tool, the accuracy of landmark-basedtechniques ranged between 39% and 50%.33,40 With the use ofultrasound, the accuracy was high (95%Y100%) in cadaver stud-ies.38,41 With a landmark-based technique, the accuracy did notdiffer significantly with different levels of experience (specialist,resident, or student).39,41

Ultrasound-Guided Injection TechniqueThe patient position can be either in sitting (chair with back

support) or supine position. The arm should be in the neutralposition, as the deep joint space is the widest at this position.42 Alinear probe with high frequency is used because the structures

FIGURE 7. A, Ultrasound image showing the presence of LHB tendon (asterisk) within the bicipital groove. The insert shows the position ofthe patient and the linear ultrasound probe. Note that the LHB tendon appears hyperechoic. B, Ultrasound image similar to A with adifferent tilt of the ultrasound probe. The image illustrates the anisotropy with the LHB tendon (asterisk) changed from a hyperechoic toa hypoechoic structure. The insert shows the position of the probe and the corresponding anatomic structures underneath. C, Bymoving the ultrasound probe more proximally along the orientation of the LGH tendon, a view of rotator cuff interval is shown.The LHB tendon (asterisk) is always hyperechoic at this level and sandwiched between the SS tendon laterally and subscapularis tendonmedially. The CHL (arrowheads) forms the roof of the interval. The insert on the left shows the orientation and position of the probe, andthe insert on the right shows the probe position and the structures underneath it. GT indicates greater tuberosity; LT, lesser tuberosity;SC, subscapularis. Reprinted with permission from usra.ca.

FIGURE 8. A, Ultrasound image of the SASDB. The SS tendon is seen attached laterally onto the greater tuberosity of the humeral head(H). The insert on the left shows the position of the patient and the ultrasound probe; the one on the right shows the probe and thestructures underneath. The deltoid muscle shows the underlying SS muscle. B, Ultrasound image of the SS tendon when the arm is put inthe modified Crass position. Note that the portion of the SS tendon lateral to the acromion process is significantly increased by thismaneuver. The insert shows the position of the modified Crass position. H indicates humeral head; D, deltoid muscle. Line arrows outlinethe peribursal fat of the SASDB. Reprinted with permission from usra.ca.




are superficial. The probe is placed over the medial side ofacromion in line with the clavicle. The ACJ can be visualized,with the capsule covering the 2 hyperechoic structures (acromionand clavicle). In young patients, the fibrocartilage can be seeninterposing the ACJ (Fig. 11).

Both out-of-plane and in-plane techniques have been de-scribed, but the authors’ preferred technique is out-of-plane asthe joint space is very superficial. The needle should be directedalmost parallel to the probe. Because the distance from the cap-sule to the deep joint space is approximately 4.1 T 0.9 mm,28

overzealous insertion of the needle can result in puncturing thedeep capsule and entering the subacromial space. The volume ofinjectate is usually 2 mL, and a successful injection is indicatedby the elevation of capsule and widening of the joint space underreal-time scanning.

LHB Tendon

OverviewThe main indication for injection around the LHB tendon

is biceps tendinopathy, which refers to a spectrum of pathologyranging from inflammatory tendinitis to degenerative tendi-nosis.16 Inflammation of the LHB tendon within the bicipitalgroove (primary biceps tendinitis) is uncommon.43 The vast ma-jority of biceps tendinitis is accompanied by rotator cuff tear ora SLAP (superior labrum anterior to posterior) lesion, as thesheath of the LHB tendon is an extension of the synovium of theGHJ and is closely associated with the rotator cuff (secondarybiceps tendinitis). A patient with biceps tendinitis presents withanterior shoulder pain and tenderness over the bicipital groove.Ultrasound is a useful tool that can reliably diagnose completerupture, subluxation, or dislocation of the LHB tendon but is notreliable for detecting intraarticular partial-thickness tears (overallspecificity, 97%; sensitivity, 49%).44 Magnetic resonance arthrog-raphy is the preferred method for detecting intraarticular pa-thology of the biceps tendon.45

EfficacyDespite the fact that steroid injection into the tendon sheath

is part of the recommended nonsurgical management (in addi-tion to rest, nonsteroidal anti-inflammatory drug, and physicaltherapy) described in multiple reviews, no studies have beenpublished on efficacy.15,16,46 The LHB tendon is certainly a paingenerator in the anterior aspect of the shoulder receiving bothsensory and sympathetic innervations.47 Selective injections mayfurther aid diagnosis of shoulder pathology associated with LHBtendinitis.48


To date, no comparative study on the accuracy betweenlandmark-based and ultrasound-guided techniques has been pub-lished. However, ultrasound-guided injection allows visualization

FIGURE 9. Ultrasound image of the posterior GHJ. The glenoid process and humeral head both appear as hyperechoic structureswith anechoic shadow. The insert on the top shows the position of the patient and the ultrasound probe, whereas the one below showsthe probe position and the structures underneath. B, Ultrasound image of the spinoglenoid notch by moving the ultrasound probeslightly medially. The insert shows the position of the probe and the spinoglenoid notch, as well as the suprascapular neurovascular bundle.H indicates humeral head; GP, glenoid process; SSN and SSA, suprascapular nerve and artery (line arrows in ultrasound image); SGN,spinoglenoid notch (arrowheads). *Glenoid labrum. 0Articular cartilage of the humeral head. Reprinted with permission from usra.ca.

FIGURE 10. Ultrasound image of the ACJ. The upper insert showsthe position of the probe and the patient, and the lower insertshows the position of the probe and the structures underneath.A indicates acromion process; C, clavicle. *Wedge shapefibrocartilaginous disk. Arrowheads point to the superior jointcapsule. Reprinted with permission from usra.ca.




of the anterior circumflex artery and the LHB tendon and thuspotentially avoids unintentional puncture of these structures.

Ultrasound-Guided Injection TechniqueThe patient is placed in the sitting position with a back sup-

port. A high-frequency linear probe is used. The ultrasound probeis placed over the bicipital groove (approximately midway be-tween the clavicle and anterior axillary fold) to reveal the short-axis view of the LHB tendon. A color Doppler scan is used tolocate the anterior circumflex artery. An out-of-plane approach isthe authors’ preferred method, with a 25-gauge needle insertedfrom the medial side through the transverse humeral ligament(Fig. 12). The total volume of injectate is 4 mL with 10 to 20 mgof methylprednisolone diluted in local anesthetic. Awell-directedinjection will show the local anesthetic surrounding the LHBtendons at the bicipital groove.

Glenohumeral Joint

OverviewThe main indication for GHJ injection is glenohumeral ar-

throsis and adhesive capsulitis. Glenohumeral arthrosis is char-acterized by progressive and irreversible articular destruction andfrequent involvement of the surrounding soft tissues.49 The exactprevalence is not well documented.50 Primary osteoarthritis isuncommon, and most of the causes of chondral damage are sec-ondary to trauma, instability, postsurgical arthrosis, avascularnecrosis, inflammatory arthropathy, osteochondritis dissecans,chondrolysis, and iatrogenic injury.50,51 In patients with shoulderpain, glenohumeral arthrosis is an uncommon cause of pain com-pared with other more common pathologic conditions of theshoulder. Thus, glenohumeral arthrosis is a diagnosis of shoul-der pain by exclusion.50,51 Assessment with clinical examina-tion and radiologic imaging has been discussed in a few excellentreviews.50Y53

Adhesive capsulitis (frozen shoulder) is the other indicationfor GHJ injection. The prevalence in the general population isapproximately 2% but increases with age and with the presenceof diabetes mellitus, hyperthyroidism, and hypertriglyceridemia.54

The condition is characterized by 3 phases: a painful phase last-ing 3 to 8 months followed by an adhesive phase of progressivestiffness, typically lasting 4 to 6 months, and the final resolution

or ‘‘thawing’’ phase of gradual return of motion, which usuallylasts 5 to 24 months.54,55 Conservative therapy is the mainstay ofmanagement, which includes rest, analgesia, active and passivemobilization, physiotherapy, and GHJ injection. It is impor-tant to highlight that the natural course of a frozen shoulder isusually self-limiting. It is a disease that improves over an 18- to24-month period.56 Therefore, the role of intervention is symp-tom relief and facilitation of rehabilitation.

EfficacyThe use of intraarticular corticosteroid injections for shoul-

der disorders and shoulder pain has been the subject of multi-ple systematic reviews published between 1996 and 2007.57Y61

Some reviews examined shoulder disorders and shoulder pain asa whole without interpreting their results on the basis of a spe-cific diagnosis.57,59,60 The other reviews combined the results oftrials that used single and multiple injections in their treatmentof adhesive capsulitis.59,61 The most recent systematic review,published in 2007, specifically examined the results of trials thatperformed multiple injections of corticosteroids for adhesivecapsulitis.62 They included 9 randomized controlled trials, and4 studies were rated as high quality. Three high-quality studiesshowed a beneficial effect for the use of multiple corticosteroidinjections for adhesive capsulitis with outcome measures of painreduction, improved function, and increased range of shouldermovement. They concluded that multiple injections were bene-ficial until 16 weeks from the date of the first injection. In termsof multiple injections, their review supported that up to 3 in-jections were beneficial, but there was limited evidence that 4to 6 injections were beneficial. The role of GHJ injection as partof the conservative therapies for adhesive capsulitis needs to beemphasized. Intraarticular steroid injection has been shown toproduce significant reduction in pain and disability after treat-ment with corticosteroid injections plus exercise versus exercisealone.63

Although there is some evidence to support the use of intra-articular steroid injection in adhesive capsulitis, the role in theconservative management of GHJ arthrosis is unclear. There areno studies specifically addressing the efficacy in GHJ arthro-sis.52 A recent practice guideline from the American Academy of

FIGURE 11. The insert shows the position of the ultrasound probeand the needle with the out-of-plane technique. The correspondingultrasound image shows the ACJ with the image of the needle(solid arrow). The arrows outline the superior joint capsule.Reprinted with permission from usra.ca.

FIGURE 12. The insert shows the position of the ultrasoundprobe and the needle with the out-of-plane technique. The localanesthetic is seen surrounding the bicep tendons in the bicipitalgroove (line arrows). The black arrowhead points to the anteriorcircumflex artery. GT indicates greater tuberosity; LT, lessertuberosity. Reprinted with permission from usra.ca.




Orthopedic Surgery found no evidence to support or refute theuse of intraarticular corticosteroid injection for the treatment ofGHJ arthrosis.64 Systematic review of steroid injections for os-teoarthritis of the knee demonstrated modest pain relief 2 to3 weeks after injection, but there was no benefit over placebo atany time point beyond 4 weeks.65 The analgesic benefit fromGHJ steroid injection, if any, is likely short term.

Apart from steroid, hyaluronic acid has been used for GHJarthrosis. Hyaluronic acid, a large-molecular-weight glycosami-noglycan, is a constituent of synovial fluid in normal and osteo-arthritic joints and is widely used for the treatment of osteoarthritisof the knee.66 Despite the considerable ongoing controversy re-garding its efficacy, cost-effectiveness, and benefit-to-risk ratio,the intraarticular injection of hyaluronan is recommended in 8 of9 existing guidelines as a useful therapeutic modality for treat-ing patients with osteoarthritis of the knee.65 A recent large,randomized controlled trial,67 supported by the drug company thatproduced the hyaluronan, investigated the effects of 5 weeklyand 3 weekly intraarticular injections of hyaluronan on a mixedpopulation of patients with persistent shoulder pain (GHJ osteo-arthritis, rotator cuff tear, and/or adhesive capsulitis). There was asignificant placebo effect shown in the placebo group, but bothactive treatment groups demonstrated significant long-term an-algesic effects (913 weeks). However, in the subanalysis whenonly the patients with GHJ osteoarthritis with or without othershoulder pathology were included in the analysis, both of thesetreatment groups were superior to placebo groups in pain reliefin almost all time measurements (weeks 7, 9, 17, and 26). Thislent support for use of the hyaluronan in the GHJ osteoarthritispatient. The treatment was well tolerated by the patients.


Although many practitioners use a landmark-based tech-nique, the use of image guidance (ultrasound or fluoroscopy) isalso very popular. In general, the validation studies can be di-vided into cadaveric and clinical studies. The validation methodsto confirm the placement of the injectate are cadaver dissection,x-ray/fluoroscopy, and magnetic resonance imaging (MRI).

For the landmark-based technique, the overall success ratesof the validation studies range from 27% to 100%.68Y75 Incontrast, the success rates of the ultrasound-guided studies wereall 100%, with the exception of 2 studies.76Y84 In a study, thesuccess rate was 97%, with failure in one patient due to obesityand the presence of vasovagal response.78 The authors attributedthe failure to the thick subcutaneous soft tissues and difficulty inobtaining good visualization of the deep tissues with a super-ficial probe. In another study, 2 approaches (anterior and pos-terior) with ultrasound-guided injection were used, althoughanterior approach was used in 87% (118/135 patients) of thepatients.82 Not surprisingly, the success rate of the more preva-lent approach (anterior) was 95% (118 patients), whereas the ratewas 41% for the posterior approach (27 patients). An interestingcomparison study was conducted examining the ultrasound-guided approach and landmark-based (conventional) approachin various joint interventions.85 The ultrasound-guided injec-tions were all performed by a rheumatology trainee (9 months inrheumatology program with 8 sessions of MSK ultrasound train-ing), and the conventional approach was all performed by 9 rheu-matology consultants with a median of 9 years of experience.The accuracy rates were 63% and 40% for the ultrasound andconventional groups, respectively. Despite the contrast in expe-rience, the trainee achieved a better accuracy, which was asso-ciated with better pain relief at the sixth week.

Radiologic guidance provides excellent accuracy but ex-poses the patients to radiation.86Y90 Direct comparison betweenultrasound-guided and fluoroscopy-guided injections performedby experienced radiologists had been investigated with excellentaccuracy in both groups (100%).86,87 Although both techniquesachieved the same success rate, ultrasound-guided techniquemanaged with higher first-attempt rate, less time spent, andlower patient discomfort.87

Ultrasound-Guided Injection TechniqueUltrasound-guided injections of the GHJ have been suc-

cessfully demonstrated, irrespective of the approaches (anterioror posterior). The posterior approach has been advocated as thepreferred approach because of the presence of fewer stabilizers(such as GHL), absence of important articular structures (suchas capsulolabral complex), and less extravasation.78 Rotator cuffinterval has been recently described with the theoretical advan-tages of avoiding the anterior stabilizers and articular struc-tures.81 All 3 approaches are described:& Posterior approach. The patient can be in either sitting orsemiprone position, with the ipsilateral hand crossing the chest.A linear probe is sufficient for most patients, except thosewithvery high body mass index, in which a low-frequency curveprobe is used. The scapular spine is palpated, and the ultra-sound probe is placed just caudal and parallel to the lateral endof the spine. With this position, the IS muscle, humeral head,posterior glenoid rim, and labrum are revealed (Fig. 13A). A20- or 22-gauge needle is inserted in-plane from the lateralaspect of the probe and directed between the free edge of thelabrum and the hypoechoic articular cartilage of the humeralhead. With the injection of normal saline, the posterior jointcapsule is seen displaced. If one encounters resistance on in-jection, the bevel of the needle can be rotated, or the needlecan be withdrawn for a small distance.

& Anterior approach. The patient is put in supine position, withthe arm externally rotated. A low-frequency curve probe isused in a muscular or obese patient. The probe is placed caudaland parallel to the acromion, with the medial part covering thecoracoid process. With this position, the humeral head, SCmuscle, and coracoid process are revealed (Fig. 13 B). A 20-or 22-gauge needle is inserted in-plane from the lateral sideof the probe aiming at the medial border of the humeralhead. The beveled side of the needle is adjacent to the humeralhead to facilitate the entry of the injectate. Correct position ofthe needle tip results in the injectate flowing in the directionof the subscapular recess and joint space.

& Rotator cuff interval. The patient is placed in supine position,with the arm in neutral position. A linear probe is placed abovethe bicipital groove, showing the transverse view of the LGBtendon. With the probe in this position, the LHB, SS, and SCtendons, SGHL, and CHL are revealed (Fig. 7C). The authorsprefer an out-of-plane technique to direct the needle into theGHJ through the space on either side of LHB tendon.

Subacromial Subdeltoid Bursa

OverviewShoulder pain is one of the common complaints to physi-

cians in general practice, accounting for 11 to 12 per 1000 con-sultations,90 and subacromial impingement syndrome accountsfor the most common diagnosis.91 The indication for SASBDinjection is subacromial impingement syndrome, which coversa constellation of conditions: partial- and full-thickness rotatorcuff tear and rotator cuff tendinopathy.92




The rotator cuff tear can be articular sided, bursal sided, orintratendinous, and the incidence increases with age.93,94 Rotatorcuff tendinopathy is a generic term without etiologic, biochem-ical, or histologic implications and is used to describe pathologyin and pain arising from a tendon.22 The common presentationsof patients with rotator cuff disease are pain and stiffness. Painis the predominant symptom, often most troubling at night andwith overhead activities. Partial tendon lesions are often muchmore painful than full-thickness tears.95 The natural history ofpartial-thickness tears of the rotator cuff is not completely elu-cidated, but there is a substantial body of circumstantial evidenceto suggest that most partial tears do not heal on their own and thatmost of these tears progress to become larger rather than smallerwith time.96 Initially, these tears should be managed with rest,activity modification, and nonsteroidal anti-inflammatory drugs.Physical therapy for range of motion should then begin, with thegoal of regaining any motion lost because of capsular contrac-tures.97 Although there is a paucity of reliable reports on theclinical outcome of conservative treatment of partial tears, mostpatients will improve with conservative measures over 6 months;some continue to improve for up to 18 months.96 In patientswithout response to the initial conservative therapy or with se-vere shoulder pain, SASDB injection can be considered.

EfficacyThere are multiple reviews on the efficacy of SASDB in-

jections for rotator cuff disease.58Y60,98Y101 Because of differentmethodologies and inclusion criteria, the results of those re-views vary. One review incorporated a study that included aninjectable nonsteroidal anti-inflammatory medication amongother trials assessing the efficacy of steroid injections.101 An-other included articles that either did not specifically addressrotator cuff pathology or had critical methodological flaws.98

Two other reviews appraised the efficacy of steroid injection forseveral shoulder conditions.59,60 The Cochrane review was up-dated only until 2003.58 The systematic review performed byKoester et al100 is the most recent review that included 9 ran-domized controlled trials specifically appraising the use of

subacromial steroid injections in rotator cuff disease. Their con-clusion was that subacromial steroid injection is not efficaciousin the treatment of rotator cuff disease. It is important to note thatthe injection techniques included in those 9 studies were all‘‘blind’’ injection, with the exception of 1 study in which x-rayconfirmation was performed in a portion of the patients. Theaccuracy of x-rayYguided SASDB injection will be discussedin the following section.

In a practical clinical setting, the subacromial injection isusually performed in a multimodal approach with physiotherapyor a rehabilitation protocol. A recent large, pragmatic, random-ized controlled trial showed that the subacromial steroid injec-tion decreased pain and improved functional outcome at 1 and6 weeks, and there was no difference compared with exercisealone at 3 and 6 months.102 The absence of long-term efficacyis not uncommon for interventions of common MSK problems.In examining results from recent high-quality randomized con-trolled trials for common MSK disorders, Foster et al103 foundno or very small differences in the effectiveness of differentapproaches when based on long-term outcomes (6Y12 months).This has been exemplified by the various shoulder injectiontechniques described in the previous sections.


The accuracy of the blind approach has been investigatedin a number of studies. With the exception of the study by Ruttenet al104 (which showed 100% success rate), the success rateranged from 29% to 70% in all clinical studies68,105Y109 and 70%to 91% in cadaver studies.37,110,111 Various approaches for theblind injection have been described (posterior, anterolateral, andlateral), but there are no differences in their accuracy rates.105,108,111

The experience and confidence of the practitioners did not in-fluence the accuracy rate. In studies where the blind procedureswere performed by very experienced orthopedic surgeons andshoulder specialists, the confidence correlation (the accuracy ratewhen the practitioners were very confident that they were ac-curate) ranged from 42% to 66%.105,109

FIGURE 13. A, Posterior approach to the GHJ. The insert (left upper) shows the position of the ultrasound probe and the needle within-plane technique. The corresponding ultrasound image (right) is shown with the line representing the needle path, which was directedbetween the free edge of the labrum (*) and the hypoechoic articular cartilage (&) of the humeral head (H). G indicates glenoid. Insertin the lower left shows the anatomic drawing of the ultrasound image. B, Anterior approach to the GHJ. The insert (left upper) showsthe position of the ultrasound probe and the needle with in-plane technique. The corresponding ultrasound image (right) is shownwith the line representing the needle path, which was inserted from the lateral side of the probe aiming at the medial border ofthe humeral head (H). CP indicates coracoid process. *Subscapularis tendon. Insert in the lower left shows the anatomic drawing ofthe ultrasound image. Reprinted with permission from usra.ca.




The imaging methods used for validation were mostly by x-ray,69,107,109 althoughMRI105,112 and ultrasound104 were also used.Mathews and Glousman111 found that x-ray was an unreliablemethod in confirming the location of contrast in the subacromialspace when the result was validated with cadaver dissection.Ultrasound-guided injection was validated with MRI in onestudy, and the accuracy was 100%.112 The use of the ultrasound-imaging technique in the diagnosis of the rotator cuff diseasehas been extensively investigated, and the reliability is compa-rable with that from MRI.112Y115

With the landmark-based approach, the injectate wasfound in deltoid muscle, SS tendon, SC muscle, GHJ, andACJ.37,105Y107,111 The accurate location of steroid in theSASDB correlated with superior outcome in the shortterm106,108 and in the intermediate term (2Y6 weeks).69,106 Thereare 3 studies comparing the pain and functional outcome be-tween the ultrasound-guided injection and blind injection groupswithout validating the location of the injectate in the blindgroups.116Y118 Hashiuchi et al117 found a better pain score in theultrasound group at 30 minutes, and Ucuncu et al118 showed su-perior pain and functional outcome at 6 weeks in the ultrasoundgroup, whereas Chen et al did not demonstrate a difference.116

Ultrasound-Guided Injection TechniqueThe patient can be placed either in the supine or sitting

position, with the ipsilateral arm in the modified Crass position(the palmar surface of the hand touching the buttock). A high-frequency linear probe is placed with the medial end over theacromion and the orientation perpendicular to the coracoacro-mial arch (Fig. 14). With this position, the SASDB is outlined bythe peribursal fat between the deltoid muscle and SS tendon. Anin-plane approach is the authors’ preferred approach, with theneedle inserted from lateral to medial direction. In some indi-viduals with slim build, the probe can be better stabilized byturning the probe 90 degrees. The needle can be inserted in-plane

from anterior to posterior direction (Fig. 14). Forty milligrams ofmethylprednisolone or triamcinolone mixed with 4 to 6 mL oflocal anesthetics may be injected.

CONCLUSIONSApplication of ultrasound for shoulder injection is in-

creasingly popular. Ultrasonography allows accurate localizationof the various target structures for shoulder injections and real-time guidance of the needle insertion. A good understanding ofthe anatomy and sonoanatomy is of paramount importance inperforming the ultrasound-guided injections.

ACKNOWLEDGMENTSThe authors thank Qing Huang for her exceptional medical

drawings and Alex Yeung and Cyrus Tse for their assistance withthe illustration and photography.

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FIGURE 14. The insert on the left shows the position of theultrasound probe and the needle with the in-plane technique.Note that the medial end of the ultrasound probe is placed overthe acromion (Acr). However, in a patient with a slim bodybuild, the probe can be placed in another orientation as shownin the right insert. The ultrasound image on the left shows theneedle (arrowheads) inserted with in-plane technique to theSASDB, as highlighted by the peribursal fat (line arrows). Theimage on the right shows the presence of local anestheticfollowing the injection, with the separation of the deltoid muscle(D) and SS tendon. Reprinted with permission from usra.ca.




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