3.1.1 Cause

• 
  

  Most commonly idiopathic.

  
  
• 
  

  May be due to an underlying osteoarthritis or rheumatoid arthritis.

  
  
• 
  

  Secondary to trauma or postsurgery.

3.1.2 Presentation

• 
  

  Pain felt in the shoulder region with referral into the upper arm.

  
  
• 
  

  Occasionally, pain may radiate as far as the hand.

  
  
• 
  

  The shoulder presents in a classic capsular pattern of restriction with a painful loss of the following:

  
  
  
  
  • 
    

    Most lateral rotation with a hard end feel.

    
    
  • 
    

    Less abduction.

    
    
  • 
    

    Least medial rotation.

3.1.3 Equipment

See Table  3‑1.

3.1.4 Anatomical Considerations

The safest and easiest technique is to use a posterior approach. The clinician need not worry about any major blood vessels or nerves if this technique is used and the posterior curve of the humeral head gives a clear angle to direct the needle.

3.1.5 Procedure

• 
  

  The patient sits facing the ultrasound machine with the arm to be injected resting across their stomach.

  
  
• 
  

  Identify the spine of the scapula and place the transducer immediately below this in a parallel line.

  
  
• 
  

  The needle is inserted at approximately 45 degrees to the transducer from a posterolateral to anteromedial direction.

  
  
• 
  

  Using the posterior curve of the humeral head as a guide, direct the needle deep to the infraspinatus muscle and posterior labrum.

  
  
• 
  

  The injection is given as a bolus and should flow freely.

3.1.6 The Injection

See Fig.  3‑1 andFig.  3‑2.

3.1.7 Notes

In the acute stages the injection may be given up to three times at monthly intervals to facilitate a programme of stretching which should be prescribed without delay. If a more chronic shoulder presents with restriction of movement being more of a problem than pain a much higher volume may be given to cause a stretching (hydrodilatation) of the capsule. This may be of particular benefit in the diabetic frozen shoulder.

If a hydrodilatation effect is required, then the technique described above is utilized, but in addition to injection of corticosteroid and local anaesthetic up to 40 mL of normal saline is also injected. If this technique is adopted, it is useful to use a low-pressure tubing with one clinician directing the needle under guidance and a second clinician controlling the syringe. To facilitate the best possible outcome, a course of vigorous stretching must be immediately implemented.

3.2.1 Cause

• 
  

  Overuse/excessive use.

  
  
• 
  

  Trauma.

  
  
• 
  

  Idiopathic.

3.2.2 Presentation

• 
  

  Pain felt in the region of the shoulder with referral into the upper arm to elbow. Occasionally, pain may radiate as far as the hand or into the scapular region.

  
  
• 
  

  Pain may be felt in all directions if acute, but no capsular restriction should be noted.

  
  
• 
  

  A painful arc may be present midrange flexion and abduction with positive Neer’s sign and Hawkins–Kennedy test.

3.2.3 Equipment

See Table  3‑2.

3.2.4 Anatomical Considerations

The subacromial bursa extends from below the acromion to lie over the anterolateral aspect of the humeral head. It may be variable in size and loculated particularly if the problem is chronic.

3.2.5 Procedure

• 
  

  The patient sits facing the ultrasound machine with the arm in extension and their hand resting on their ipsilateral hip.

  
  
• 
  

  The transducer is placed transversely over the underlying subacromial bursa and supraspinatus tendon immediately below the anterior edge of the acromion.

  
  
• 
  

  The needle is inserted at approximately 45 degrees to the transducer from a posterolateral to anteromedial direction.

  
  
• 
  

  The injection is given as a bolus and should flow freely with distension of the bursa noted.

3.2.6 The Injection

See Fig.  3‑3 and Fig.  3‑4.