MSK Ultrasound Procedures


Shoulder Therapeutic Injection



Equipment and Medications

  • probe: Linear 9 or 14 MHz will suffice in most cases, curved 6-8Mhz in patients with large body habitus
  • 22g spinal needle 3.5” (typically, length depends on body habitus)
  • 25 g 1.5” needle
  • 10cc syringe with lidocaine 1%
  • 5cc syringe with 1-2 cc of injectable steroid (kenalog 40mg/cc) + 3cc 0.5% ropivacaine
  • Procedure tray

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    Equipment

    Medications


    Procedure Instructions:

    Instructions
    1. Standard pre procedure workup (consent, indications, contraindications, allergies, diabetes history, pain level 1-10)  
    2. Position patient with lateral decubitus with contralateral shoulder down with arm in cross adduction.
    3. Scan patient looking for the posterior glenohumeral joint space. Image at the level of the infraspinatus tendon insertion in longitudinal orientation. Position probe so you can inject from anterior.
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      • Mouse over image for annotated version.
    4. Mark needle site and probable injection site.  
    5.  Prep patient; betadine or chlorhexidine x 3. Clear wide area.  
    6. Place sterile drape and probe cover.  
    7. Draw up medications as listed in equipment list.  
    8. Place sterile ultrasound probe on skin and find site of injection again and inject 1% lidocaine superficially via the 25g 1.5” needle.  
    9. Exchange 25g 1.5" needle for the 22g 3.5” needle  
    10. Advance needle under ultrasound guidance to the level of the articular cartilage (hypoechoic line).
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      • At this point the needle tip is not quite at the articular cartilage and still within the overlying deltoid muscle.
    11. Test inject to see if easy flow with 1% lidocaine. Look for accumulation of fluid or microbubbles in overlying soft tissue. If no resistance and see distention of the joint space exchange for 5cc syringe with injectable steroid and ropivacaine mixture. If resistance, spin needle or slightly pull back needle to step off articular cartilage.
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      • Needle has been advanced and is about to broach the infraspinatus tendon. If one were to do a test injection at this point, there would be resistance to flow.
    12. Inject 5cc syringe with injectable steroid and anesthetic solution described above.
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      • After advancing the needle to the level of the articular cartilage, there is easy flow of the injectate.
    13. Document distention of the posterior joint recess with ultrasound.
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    14. Clean off area and place bandage over skin  
    15. Ask about pain and give patient pain log.

    		 

     

    References

    1. Zwar, Read, and Noakes. "Sonographically Guided Glenohumeral Joint Injection." AJR July 2004 vol. 183 no. 148-150.