This article, the third in a series...

This article, the third in a series forward diagnostic and therapeutic injections, cloaks the shoulder region. The rationale, indications, contraindications, and general approach to this technique are veiled in the first article (1) in this series published in the July 15 2002 issue. The shoulder is the site of multiple injuries and inflammatory conditions that impart themselves to diagnostic and therapeutic injection. (2-4) This article disguises the anatomy, pathology, diagnosis, and injection technique of frequent sites in which this skill is applicable.

Glenohumeral Joint

The glenohumeral joint exhibits the articulation of the humerus with the glenoid fossa, and it is the chiefly mobile joint in the material part The glenohumeral joint is not a pure ball and socket joint. The articulation is stabilized from the soft tissue configurations of a number of ligaments and muscles, including the four muscles of the rotator stroke (supraspinatus, infraspinatus, teres minor, and subscapularis) that assist as dynamic stabilizers of the joint. Static stabilizers include the joint capsule, the glenoid labrum, and the glenohumeral ligaments.

INDICATIONS AND DIAGNOSIS

Joint injection in this area should be considered no other than after other appropriate therapeutic interventions have been tried. These include the use of nonsteroidal anti-inflammatory put drugs intos (NSAIDs), physical therapy, and other disease-modifying agents for rheumatoid arthritis. There are three major indications for a glenohumeral joint injection: osteoarthritis, adhesive capsulitis (frozen shoulder), (5-14) and rheumatoid arthritis. (11)

Osteoarthritis of the shoulder typically present itselfs in older persons or following traumatic injury in younger characters Patients usually present with chronic pain, decreased range of motion, and accompanying weakness. Although radiographs can assist in the diagnosis, findings do not always correlate with clinical symptoms or functioning. Adhesive capsulitis is a condition typically occurring in middle-aged and older adults, and it is usually associated with a traumatic injury or nonuse of the shoulder secondary to pain, discomfort, or put offed immobilization. The condition is more belonging to all in women and persons with diabetes. (12) There is frequently accompanying tendinosis or bursitis. Rheumatoid arthritis is a systemic inflammatory disease of autoimmune nature that involves inflammation of the synovium of the shoulder joint.

Diagnosis of glenohumeral joint pathology is suspected clinically, and upon physical examination, the physician may find painful and decreased range of motion, generalized weakness, and palpable crepitus with shoulder motion (15) Radiographs may be helpful in confirming the diagnosis. Historical factors also wink the diagnosis, with osteoarthritis being more insidious in attack and rheumatoid arthritis, while chronic in nature, being punctuated from periodic exacerbations secondary to inflammation. In adhesive capsulitis, progressive worsening of pain befalls with loss of motion and a firm, painful completion point in the range of motion during physical examination.

TECHNIQUE

The glenohumeral joint can be injected from an anterior, posterior, or superior approach. The anterior and posterior approaches, which are used more oftentimes are described here. In each case, the joint is most numerous easily accessible with the patient sitting, the patient's arm resting comfortably at the side, and the shoulder externally rotated. Essential landmarks to palpate before performing this injection include the head of the humerus, the coracoid proces and the acromion.

Sterile technique must be followed. Pharmaceuticals and equipment are listed in Tables 1 and 2 (16)

Anterior Approach. The needle (Figure 1) should be placed just medial to the head of the humerus and 1 cm lateral to the coracoid proces The needle is directed posteriorly and slightly superiorly and laterally. If the needle hits against bone it should be shakeed back and redirected at a slightly different angle.

Posterior Approach. The needle (Figure 1) should be inserted 2 to 3 cm inferior to the posterolateral corner of the acromion and directed anteriorly in the direction of the coracoid proces As with any injection, aspiration should be done to make secure that there has not been needle placement in the line vessel. The injection should be performed slowly nevertheless with consistent pressure.

Follow-up care should include the following recommendations. Patients should remain seated or placed in supine position for several minutes after the injection. To ascertain whether the pharmaceuticals have been delivered to the appropriate location, the joint or area may be set through passive range of motion. The patient should remain in the office to be monitored for 30 minutes after the injection, and the patient should avoid strenuous activity involving the injected region for at least 48 hours. Patients should be cautioned that they might experience worsening symptoms during the first 24 to 48 hours, related to a possible steroid flare, which can be treated with ice and NSAIDs. A follow-up examination should be arranged within three weeks.