Shoulder Injections What, Where, When, Why and How

Lennard Funk

Southend, 2006

Why Inject??

• Reduce inflammation

• Relieve pain

• Facilitate rehabilitation

Impingement

• Rotator Cuff Dysfunction

• Impingement

• Compression of Bursa

• Bursitis

• Further Dysfunction

Impingement

• Rotator Cuff Dysfunction

• Impingement

• Compression of Bursa

• Bursitis

• Further Dysfunction

Impingement

• Management needs to break cycle

• Improvement of Cuff Dysfunction through physiotherapy

• Very difficult to engage with rehabilitation if painful

When to Inject?

• Mid arc “impingement pain”

• Symptom Modification Tests

• (Imaging - USS / MRI)

• Occasionally unclear

• Diagnostic Injection

Scapula Correction & Assistance Testing

• Ben Kibler

SSMP• Jeremy Lewis

• Improvement but not complete with SSMP

• NEED:

• Education

• Relative Rest

• Lifestyle Modification

• Compliance

When to Inject?

Subacromial Injections

• Blind / USS

• Posterior

• or Anterior / Lateral

Subacromial Injections

• Accuracy (Henkus, 2006)

• 76% via the posterior approach,

• 69% via anteromedial approaches .

• 66% correlation between the injector’s confidence in being in the subacromial bursa and accuracy as confirmed on post-injection MRI scanning.  

• accurate injection was associated with good pain reduction

Subacromial Injections

• Accuracy - USS guided

• Naredo et al: RCT of 41 patients between USS guided and blind injections - significant improvement in results at 5 weeks with USS (J Rheumatol 21(2):308-14)

• Chen et al: RCT of 40 patients - no difference in pain or function but was an increased abduction range with USS guided (Am J Phys Med Rehab 85(1):31-5)

Subacromial Injections

• Accuracy - USS guided

• “unable to establish any advantage in terms of pain, function, shoulder range of motion or safety, of ultrasound-guided glucocorticoid injection for shoulder disorders over either landmark-guided or intramuscular injection”

Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev. 2012 Aug 15;8

Subacromial Injections

• Accuracy

• USS guided injections probably more accurate

• USS guided injections possibly more effective

• Evidence limited

• Significant difference in costs / availability

What to Inject?• Corticosteroids:

• inhibits tendon cell migration that is correlated with decreased gene expression of a-SM actin [Tsai et al. JOR, 2003]

• adversely affect human tenocytes in cell culture [Wong et al. JBJS, 2003]

• significantly weakens both intact and injured rat rotator cuff tendons. Transient effect [Mikolyzk et al. JBJS, 2009]

• The increases in cell proliferation, vascularity and HIF-1α after surgical rotator cuff repair appear consistent with a proliferative healing response, and these features are not seen after glucocorticoid injection [Dean et al. BJSM, 2014]

• repeated doses significantly weaken rat RC and negatively affect bone quality [Marman et al. AJMS, 2016]

What to Inject?• Corticosteroids:

• inhibits tendon cell migration that is correlated with decreased gene expression of a-SM actin [Tsai et al. JOR, 2003]

• adversely affect human tenocytes in cell culture [Wong et al. JBJS, 2003]

• significantly weakens both intact and injured rat rotator cuff tendons. Transient effect [Mikolyzk et al. JBJS, 2009]

• The increases in cell proliferation, vascularity and HIF-1α after surgical rotator cuff repair appear consistent with a proliferative healing response, and these features are not seen after glucocorticoid injection [Dean et al. BJSM, 2014]

• repeated doses significantly weaken rat RC and negatively affect bone quality [Marman et al. AJMS, 2016]

What to Inject?• Corticosteroids:

• inhibits tendon cell migration that is correlated with decreased gene expression of a-SM actin [Tsai et al. JOR, 2003]

• adversely affect human tenocytes in cell culture [Wong et al. JBJS, 2003]

• significantly weakens both intact and injured rat rotator cuff tendons. Transient effect [Mikolyzk et al. JBJS, 2009]

• The increases in cell proliferation, vascularity and HIF-1α after surgical rotator cuff repair appear consistent with a proliferative healing response, and these features are not seen after glucocorticoid injection [Dean et al. BJSM, 2014]

• repeated doses significantly weaken rat RC and negatively affect bone quality [Marman et al. AJMS, 2016]

What to Inject?• Steroids RCTs:

• Chen (2010) - RCT No difference with placebo at 1 week but improved scores at 6 weeks (JSES 19(4):557-63)

• Cochrane Review, 2003: 26 Trails:

• “Despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained.

What to Inject• Hyaluronans

• Anti-inflammatory

• Pain mediation

• Stimulates endogenous HA

• Safer than corticosteroids

• Not Prohibited by WADA

What to Inject?

• Steroids vs HA:

• Shibata (2001) - HA Similar results to steroid (JSES 10(3):209-16)

• Blain (2008) - better results with HA but no difference between 3 and 5 injections

• Penning (2012) - better short-term effect with steroid but no difference at 26 weeks (JBJS Br 21(6):722-7)

Platelet Rich Plasmas• Very topical

• Good in vitro evidence

• No benefit demonstrated in vivo for shoulder surgery of PRP, L-PRP, PRF or L-PRF

Zumstein MA, Berger S, Schober M, Boileau P, Nyffeler RW, Horn M, Dahinden CA. Leukocyte- and platelet-rich fibrin (L-PRF) for long-term delivery of growth factor in rotator cuff repair: review, preliminary results and future directions. Curr Pharm Biotechnol. 2012 Jun;13(7):1196-206

Chahal J, Van Thiel GS, Mall N, Heard W, Bach BR, Cole BJ, Nicholson GP, Verma NN, Whelan DB, Romeo AA. The role of platelet-rich plasma in arthroscopic rotator cuff repair: a systematic review with quantitative synthesis. Arthroscopy. 2012 Nov;28(11):1718-27.

Platelet Rich Plasmas

• Partial thickness / intratendinous lesions in athletes

Summary• Steroid strong anti-inflammatory

• Pain relief to aid rehab

• HA = steroid longer term

• more expensive

• USS guided improves accuracy

• ? always practical / cost-effective

• PRP - No good evidence

• ? Athlete intra-tendinous tears

Summary

• USS guided where improved accuracy is essential

• Consider Ostenil in younger patients

Glenohumeral Injections

• 2cm inferior and medial to the posterolateral corner of the acromion

• Aim to coracoid

Glenohumeral Injections

• 1cm lateral and inferior to coracoid

• Aim inferior and medial

• Internally rotate arm

Glenohumeral Injections

• Anterior approach more accurate with “normal” 21G needle.

• Especially in shoulder arthroscopistsKraeutler MJ, Cohen SB, Ciccotti MG, Dodson CC Accuracy of intra-articular injections of the glenohumeral joint through an anterior approach: arthroscopic correlation. J Shoulder Elbow Surg. 2012 Mar;21(3):380-3.

Tong A, Harding R, Graham G. Glenohumeral joint penetration with a 21-gauge standard needle. J Shoulder Elbow Surg. 2012 Dec;21(12):e1-3.

Glenohumeral Injections

• Indications

• Osteoarthritis

• Frozen Shoulder

Osteoarthritis

• Early stages when aiming to delay surgery

• Relatively uncommon

• Corticosteroids

• Unpredictable and short lived

• Possible increased infection risk

Osteoarthritis• Hyaluronans

• As effective as corticosteroids

• Possibly less side effects

• Useful in young patients - 3 injection course

Brander VA, Gomberawalla A, Chambers M, Bowen M, Nuber G. Efficacy and safety of hylan G-F 20 for symptomatic glenohumeral osteoarthritis: a prospective, pilot study. PM R. 2010 Apr;2(4):259-67.

Osteoarthritis

• Hyaluronans

• Kwon (2013) - 300 pts Multicenter double blind RCT saline vs HA: advantage of HA but not significant

• No side-effects

Kwon YW, Eisenberg G, Zuckerman JD. Sodium hyaluronate for the treatment of chronic shoulder pain associated with glenohumeral osteoarthritis: a multicenter, randomized, double-blind, placebo-controlled trial. J Shoulder Elbow Surg. 2013 May;22(5):584-94

Frozen Shoulder

• Corticosteroids

• Short term pain relief

• Limited evidence of long-term efficacy over natural history

• Technically difficult due to tight joint

Frozen Shoulder• Quraishi (2007) - better improvement and

faster with hydrodilatation vs MUA (JBJS 89(9):1197-200)

• Yoong (2015) - 86% good or complete resolution of symptoms at 4/12. 91% reduced pain (Skeletal Radiol 44(5)703-8)

• Tveita (2008) - No difference between fluoroscopic hydrodilatation vs steroid injection (BMC Musc Dis 19(9):53)

Frozen Shoulder

Frozen Shoulder

• Hydrodilatation

• Wrightington data:

• 76% improved ROM at 6 weeks

• 91% improved Pain at 6 weeks

• Maintained at 2 year follow-up

Acromioclavicular Injections

• ACJ Pain

• OA

• Osteolysis

• Part of “impingement” pathology

• Localised to the joint on palpation

Acromioclavicular Injections

• Direct palpation of ACJ

• Aim medially

• “Walk” into joint

• Max 2ml

Acromioclavicular Injections

• USS more accurate

Borbas P, Kraus T, Clement H, Grechenig S, Weinberg AM, Heidari N. The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers. J Shoulder Elbow Surg. 2012 Dec;21(12):1694-7

Long Head of Biceps

• Bicipital Tendinitis

• Possible source of pain in “impingement syndrome”

• Anterior shoulder pain

Long Head of Biceps• Bicipital injections

• Difficult

• Blind in thin patients

• USS much more accurate

• Hyaluronan in young patients - theoretical reduced risk of iatrogenic tendon rupture

Summary

• Injections reduce pain & inflammation

• Facilitate rehabilitation

• USS guidance is more accurate but more costly

• Hyaluranon may be better in young patients

• PRP may have role in Intratendinous tears

LESS STEROID ATTACKS!

Lennard Funk Shoulder Surgeon

Adam Watts Upper Limb Surgeon

Puneet Monga Shoulder Surgeon

Mike Walton Shoulder Surgeon

Will Tatlow PA to Len Funk

Marie Yates PA to Adam Watts

Debbie Lester PA to Walton & Monga

Linda Hallam Surgical Assistant

Dorothy Chow Practice Admin.

Emma Torrance Research & Outcomes