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Techniques for "Blind" Glucocorticosteroid Injections into Glenohumeral Joints

To the Editor:

Corticosteroid injections into glenohumeral joints have long been a valuable adjunct therapy in managing selected patients with localized persistent pain usually accompanied by decreased range of motion (ROM). Such local injections are performed by rheumatologists¹ , orthopedic surgeons² , and other physicians³. The accuracy of intraarticular injections into shoulder^1-3 or other^1,4 joints has been emphasized for achieving optimal patient comfort and therapeutic benefit^1-7.

In a recent article in The Journal⁶ , a study reporting a low 42% accuracy of glenohumeral injections confirmed by radiographic contrast dye⁸ was cited. That cadaveric study⁶ evaluated positional and bony landmark techniques to improve subacromial and glenohumeral injection accuracy and to limit dye dispersal, without radiologic or fluoroscopic imaging assistance, i.e., using "blind" clinical techniques. Another recent cadaveric study⁷ indicated greater (p = 0.04) accuracy of an anterior [16 of 20 (80%)] than posterior [10 of 20 (50%)] shoulder approach. In that study⁷ , accuracy was determined fluoroscopically, after injecting contrast dye. A recent letter⁹ described conflicting reports of anterior glenohumeral injection accuracy given at the 2006 Annual Meeting of the New England Shoulder and Elbow Society (Jay Peak, VT, USA; January 28-29, 2006), from low (Dr. Patel) to excellent results (Dr. K. Shea).

Considering current concerns and controversy about "blind" shoulder injection techniques, selected aspects of our procedures are summarized (Table 1) that reflect over 100 person-years' experience^1,5. The estimated therapeutic injection success rates are based upon patients' reported post-injection decrease in symptoms, improved shoulder ROM measurements, and followup evaluations. However, anatomical accuracy of injection placement was not confirmed using contrast radiography^6,7,9. Such imaging procedures were not considered necessary in achieving our desired satisfactory clinical results. Reliable performance of this common steroid injection is expected in clinical practice, provided that sufficient instruction in anatomical landmarks and procedural experience have been acquired^1,5,6. When injecting via the anterior approach, our needle entry site is immediately lateral to the deeply palpated anterolateral edge of the coracoid process^2,7 (Table 1), not at 1 cm lateral to the coracoid, as described³. The site is on a palpable "groove" between the coracoid process and the humeral head. It is also important to gently penetrate the soft tissues with a thin 1.5-in needle, avoiding bony contact or increased resistance, until the hub of the needle presses against the skin and a sensation of "popping" through the anterior capsule is noted^2,7 (Table 1). Such technique achieves sufficient depth of injection in almost all adult patients.

Table 1. Summary of corticosteroid injection techniques into glenohumeral joints.

Debate on adverse consequences of inaccurate glenohumeral steroid injections may be mitigated by the very nature of the instilled steroid agents. Inaccurate instillation of steroids into paraarticular nontendinous soft tissues may not be harmful, and may still confer benefit to the patient^2,9. Instillation may not need to be entirely and accurately placed within the shoulder joint cavity to achieve clinical benefits. In the future, however, hyaluronan products likely will be injected into shoulder joints for osteoarthritis-related persistent pain and loss of motion^10,11. Such injections will likely require refined techniques with strict criteria for accuracy of needle placement and instillations⁹. Paraarticular infiltration with hyaluronan may cause discomfort and "after-pain" or possibly an "inflammatory (pain)" reaction^9,12 that is less likely to confer benefit. Ultrasound, radiographic, or fluoroscopic guidance may deserve consideration with hyaluronan shoulder injections, but did not appear needed in a large-scale controlled study^10,11.

The recent Journal article⁶ further signals that accuracy of shoulder joint injections should be a key consideration for clinicians and investigators alike. Anatomical and positional factors should be optimized to achieve accuracy of glenohumeral injections and maximal patient comfort, with either anterior or posterior approaches^1-8 (Table 1). Additional objective data are needed in order to achieve clinical accuracy and efficacy of steroid therapy^1-8 and expected future hyaluronan^9-11 shoulder injections. Our comments do not address issues of clinical indications, cost-effectiveness, or side effects of shoulder joint injection therapy, which also require further investigation.

ALFONSE T. MASI, MD, DrPh, University of Illinois College of Medicine at Peoria; RICHARD P. DRIESSNACK, MD, Orthopedic Institute of Illinois; MUHAMMAD B. YUNUS, MD, University of Illinois College of Medicine at Peoria, Peoria, Illinois; DAVID H. NEUSTADT, MD, University of Louisville School of Medicine, Louisville, Kentucky, USA. Address reprint requests to Dr. A. Masi, One Illini Dr., Peoria, IL 61656, USA. E-mail: amasi@uic.edu

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