Ultrasound-Guided Glenohumeral Corticosteroid Injection for the Treatment of Adhesive Capsulitis of the Shoulder: The Role of Clinical Stage in Response to Treatment

BACKGROUND

Treatment for idiopathic adhesive capsulitis of the shoulder remains controversial. Stages 1 to 2 reflect an inflammatory process supporting a rationale for intra-articular glenohumeral joint corticosteroid injection to treat synovial inflammation and prevent progression to capsular fibrosis.

HYPOTHESIS

We hypothesize that an intra-articular ultrasound-guided glenohumeral injection (USGI) of corticosteroid in patients diagnosed with Stage 1 or 2 idiopathic adhesive capsulitis will result in timely functional recovery and resolution of pain and stiffness.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Patients with Stage 1 or 2 idiopathic adhesive capsulitis treated with an intra-articular corticosteroid injection were included. Patients were seen by a single physician and diagnosed using history and physical examination with careful attention to measurement of glenohumeral range of motion (ROM). A total of 61 patients met inclusion criteria. ROM measurements documented in the patient charts were recorded in forward flexion, abduction, internal rotation, and external rotation in neutral abduction. All ROM measurements were performed pre- and postinjection. All patients were treated with an USGI of local anesthetic and depomedrol. Recovery criteria were defined as forward flexion, abduction, and external rotation within 15° of the contralateral side and internal rotation within 3 spinous process levels of the contralateral side.

RESULTS

A total of 11 patients with Stage 1 and 50 patients with Stage 2 adhesive capsulitis comprised the final study cohort. Within the Stage 1 cohort, all 11 patients met recovery criteria for forward flexion and internal rotation (100%), 10 met recovery criteria for abduction (91%), and 8 met recovery criteria for external rotation (73%). Within the Stage 2 cohort, 31 patients met recovery criteria for forward flexion (62%), 30 met recovery criteria for abduction (60%), 36 met recovery criteria for internal rotation (72%), and 25 met recovery criteria for external rotation (50%). The difference in time to recovery in days was statistically significant in all ROM planes and was within 2 to 6 weeks for patients in Stage 1 and 7 to 10 weeks for Stage 2.

CONCLUSION

USGI for early adhesive capsulitis allows patients to recover ROM more rapidly if performed early after onset of pain and stiffness.

CLINICAL RELEVANCE

These results stress the importance of recognition of idiopathic adhesive capsulitis in its early stages and subsequent intervention with an intra-articular glenohumeral corticosteroid injection.

Patient Expectations of Pain Versus Experienced Expectations of Pain Following Shoulder Injection

PURPOSE

Corticosteroids, platelet-rich plasma, and hyaluronic acid injections to either the subacromial space (SAS) or the glenohumeral joint (GHJ) of the shoulder are commonly used for diagnostic and therapeutic purposes in outpatient settings. The first aim of this study was to determine whether the anticipated pain level differed significantly from the actual pain level experienced by patients who underwent shoulder injections. The second aim was to determine whether there was a significant difference in these pain levels between SAS and GHJ injections. The secondary goal was to investigate the correlation between patients' demographic data, anxiety characteristics, and pain scores.

DESIGN

Prospective clinical study.

METHODS

This study involved patients who completed a three-part questionnaire prior as well as following an injections to the GHJ\SAS.

FINDINGS

Sixty-three patients (28 males; 35 females), mean age of 54.28 years (standard deviation 13.95, range 25 to 84) met the inclusion criteria. There was a significant difference between the anticipated and the experienced pain (visual analog score 6.03 vs 3.17, P < .001). Experienced pain of the GHJ injections (n = 34) was rated as being greater than that of the SAS injections (n = 29) with borderline significance (visual analog scale 3.79 vs 2.36; P = .05). Forty-five patients (71.42%) reported a decrease in at least one pain category between anticipated and experienced pain compared to an increase reported by two patients (3.17%).

CONCLUSIONS

Injections to the GHJ and SAS were shown to be significantly less painful than anticipated by the patients. GHJ injections were perceived as more painful than SAS injections. Communicating this evidence-based reassuring information with patients prior to an injection may alleviate fear of the procedure, reduce the perception of pain, and ultimately improve compliance with the procedure.

Assessment of 2 distinct anatomical landmarks for suprascapular nerve injection: a cadaveric study

BACKGROUND

The suprascapular nerve block (SSNB) is a commonly used procedure for the management of pain in various shoulder pathologies. Both image-guided and landmark-based techniques have been utilized successfully for SSNB, though more consensus is needed regarding the optimal method of administration. This study aims to evaluate the theoretical effectiveness of a SSNB at 2 distinct anatomic landmarks and propose a simple, reliable way of administration for future clinical use.

METHODS

Fourteen upper extremity cadaveric specimens were randomly assigned to either receive an injection 1 cm medial to the posterior acromioclavicular (AC) joint vertex or 3 cm medial to the posterior AC joint vertex. Each shoulder was injected with a 10 ml methylene blue solution at the assigned location, and gross dissection was performed to evaluate the anatomic diffusion of the dye. The presence of dye was specifically assessed at the suprascapular notch, supraspinatus fossa, and spinoglenoid notch to determine the theoretic analgesic effectiveness of a SSNB at these 2 injection sites.

RESULTS

Methylene blue diffused to the suprascapular notch in 57.1% of the 1-cm group and 100% of the 3-cm group, the supraspinatus fossa in 71.4% of the 1-cm group and 100% of the 3-cm group, and the spinoglenoid notch in 100% of the 1-cm group and 42.9% of the 3-cm group.

CONCLUSION

Given its superior coverage at the more proximal sensory branches of the suprascapular nerve, a SSNB injection performed 3 cm medial to the posterior AC joint vertex provides more clinically adequate analgesia than an injection site 1 cm medial to the AC junction. Performing a SSNB injection at this location allows for an effective method of anesthetizing the suprascapular nerve.

Ultrasound-guided injection of the long head of the biceps tendon sheath with concomitant subacromial bursa injection through the same needlestick

Sonography and specific shoulder positions allow for injections into both the long head of the biceps tendon sheath (LHBTS) and the subacromial space (SS) with one needlestick. We validated this technique using cadavers. An experienced proceduralist injected latex solution into 12 unembalmed cadaveric shoulders, aiming for the LHBTS and SS, using an ultrasound-guided injection technique that employs a single-needle entry point. An experienced surgeon dissected each specimen and graded latex location as: (1) completely accurate (in both the SS and LHBTS); (2) partially accurate (in either the SS or LHBTS); (3) accurate with overflow (in both locations, but also elsewhere); (4) partially accurate with overflow (in either location, but also somewhere else); or (5) completely inaccurate (no latex in either location). All 12 ultrasound-guided injections using the technique accurately placed latex into both LHBTS and SS (100% accuracy). Latex was also found in adjacent regions after two (17%) injections: one within the shoulder joint and one within the deltoid musculature. This newly described technique allows highly accurate access to the LHBTS and SS with single-needle entry. This technique could become a favored alternative to subjecting patients to two needlesticks and preparing separate injections to address often concomitant pathologies.