Ultrasound Guidance
Glenohumeral Joint: Intra-Articular
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Intra-articular ultrasound-guided injections can be done using the anterior rotator interval approach or posterior approach. The posterior technique avoids accidental neurovasculature injury and has lower extra-articular extravasation rates of the injectate compared to the anterior approach.
Pertinent Anatomy
See Fig. 16.1 .
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The shoulder joint (glenohumeral joint) is a ball and socket synovial joint between the scapula and the humerus.
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The joint is the major joint connecting the upper limb to the trunk.
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The joint is one of the most mobile joints in the human body, at the cost of joint stability.
Common Pathology
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Intra-articular pathology can present with a joint effusion, and distention of the joint can be seen posterior joint line or inferior axillary recess on magnetic resonance imaging (MRI).
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Patient presents with stiffness, loss of range of motion, and pain described as deep-seated anterior or posterior. Osteoarthritis can result in chronic instability from chronic ligament or tendon pathology.
Equipment
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Linear array ultrasound transducer
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25 to 22 gauge 2 to 3.5 inch needle
Common Injectates
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Local anesthetics for diagnostics
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Corticosteroids, hyaluronic acid, prolotherapy, orthobiologics (platelet-rich plasma [PRP], bone marrow concentrate, micronized adipose tissue, etc.)
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For capsular distention: High-volume mix of anesthetics, saline (corticosteroids, or orthobiologics: PRP, platelet lysate, platelet-poor plasma)
Injectate Volume
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2 to 8 mL
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20 to 60 mL for capsular distention (40 to 50 mL most common per authors’ experience). Inject maximum volume as tolerated by pain or stop when getting back flow into the syringe to avoid capsular rupture.
Technique: Glenohumeral Intra-Articular Posterior Approach
Patient Position
See Fig.16.2 .
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Lateral recumbent with elbow flexed 90 degrees and shoulder internally rotated (authors’ preferred).
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Can also have patient in the seated position with the shoulder internally rotated and hand resting in the patient’s lap or contralateral shoulder to open to posterior joint space.
Clinician Position
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Posterior to the patient
Transducer Position
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Long axis to infraspinatus tendon, starting with probe parallel and just inferior to the spine of the scapula
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Visualize the posterior glenohumeral joint line deep to the muscle belly (infraspinatus)
Needle Position
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In-plane: needle visualization from lateral to medial with target between the posterior glenoid labrum and humeral head.
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Out-of-plane: visualize the needle tip as it contacts the humeral head lateral to the posterior labrum
Target
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Glenohumeral joint space, avoiding the posterior labrum.
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Should visualize injectate flowing over the humeral head without extravagating superficial to the joint line.
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Can use power Doppler imaging to ensure intra-articular flow and no pooling outside of the joint.
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For posterior approach the needle angle can be steep, so sometimes gel stand-off can help.
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Keep needle closer to humeral head to avoid labral injury.
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With larger body habitus patient, curved linear probe may be needed.
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With capsular dilations, common to have resistance initially given the thickened capsule but with continued pressure and injectate volume into joint, flow becomes less restrictive.
Technique: Glenohumeral Intra-Articular Anterior Approach Via Rotator Interval
Patient Position
See Fig. 16.3 .
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The patient lies supine or semi-supine with the affected shoulder slightly extended, externally rotated with elbow flexed or extended for patient comfort.
Clinician Position
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Side of the affected shoulder
Transducer Position
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The transducer is placed over the anterior shoulder with a transverse view of the rotator interval. The long head of biceps tendon at the center of image and supraspinatus (SS) and subscapularis to either side is obtained.
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The coracohumeral ligament (CHL) is seen draped superiorly over the biceps tendon.
Needle Position
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In-plane: The needle is introduced into the rotator interval using a lateral to medial approach.
Target
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The needle tip is imaged in real time, and the target is the biceps tendon sheath between the CHL above and biceps tendon below.
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Can use power Doppler imaging to ensure intra-articular flow and no pooling outside of the joint.
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For frozen shoulders, anterior capsular distention via rotator interval has been shown to be superior to other techniques. ,
Subacromial Injection
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Impingement syndrome and rotator cuff pathology are a common diagnosis in patients with shoulder pain.
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Ultrasound-guided subacromial bursa injections allow for higher degree of accuracy when compared to landmark-guided injections.
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For adhesive capsulitis, both subacromial and intra-articular glenohumeral corticosteroids have been both shown to be effective.
Pertinent Anatomy
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The subacromial bursa is the largest bursa in the body and lies between the acromion (superiorly) and SS tendon (inferiorly).
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Can extend laterally towards the greater tuberosity and medially towards the acromion-clavicular joint.
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Bursa are synovial line potential space that reduces friction at the tendon-tendon and tendon-bone interface, and there are five potential bursa in the shoulder (subacromial/subdeltoid bursa, subscapularis recess/bursa, subcoracoid bursa, coracoclavicular (CC) bursa, and supra-acromial bursa).
Common Pathology
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Subacromial impingement and rotator cuff tendinosis
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Subacromial and subdeltoid bursitis
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Adhesive capsulitis
Equipment
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Linear array ultrasound transducer
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25 to 22 gauge 1.5 to 2 inch needle.
Common Injectates
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Local anesthetics for diagnostics
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Corticosteroids, hyaluronic acid, prolotherapy, orthobiologics (PRP, platelet-poor plasma).
Injectate Volume
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1 to 5 mL
Technique for Subacromial Bursa: Lateral Approach
Patient Position
See Fig. 16.4 .
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Seated upright with the shoulder fully adducted and the hand in neutral position with the elbow full extended (author preferred), or the shoulder in a Crass or modified Crass position for better visualization of the SS tendon.
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Can also have patient in the lateral decubitus position with the shoulder fully adducted and the hand in neutral position with the elbow full extended or flexed to 90 degrees.
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Additionally, can place the patient in supine position with the shoulder fully adducted and the hand in neutral or prone position with the elbow full extended.
Clinician Position
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Standing or seated adjacent to the affected shoulder
Transducer Position
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Long axis to the SS tendon.
Needle Position
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In-plane: needle visualization from lateral to medial
Target
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Subacromial bursa space with target between the undersurface of the deltoid muscle and superior to the SS tendon.
Pearls and Pitfalls
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Ensure you visualize a separation between the SS tendon and undersurface of the deltoid muscle when injecting, and your needle tip is not the SS tendon (particularly with corticosteroid injections). 6
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Consider using a longer needle (2 inches to 2.5 inches) with patients with a larger body habitus to ensure you are not injecting into the deltoid muscle.
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Consider the supine or lateral decubitus position to avoid injury from a potential vasovagal episode.
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Rotator Cuff Tendons
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Rotator cuff tears are common, and the most commonly affected tendon is the supraspinatus (SS).
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Full-thickness rotator cuff tears are present in 25% individuals over 60% and 50% of individuals over 80.
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Asymptomatic full-thickness tears are common, but 50% will become symptomatic over a 2- to 3-year period.
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The size of the tear increases in 12% to 25% of patients at 18 months, but in 50% of patients who become symptomatic, there is evidence of tear progression.
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Symptomatic full-thickness tears progress in 50% of cases over a 2-year period.
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Long-head biceps tendinopathy can have similar presentation to SS pathology.
Pertinent Anatomy
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The footprint of the SS on the greater tuberosity is much smaller compared to the footprint of the infraspinatus.
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Footprint of the SS is triangular in shape, with an average maximum medial-to-lateral length of 6.9 mm and an average maximum anteroposterior width of 12.6 mm.
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The infraspinatus had a long tendinous portion in the superior half of the muscle, which curved anteriorly and extended to the middle facet of the greater tubercle of the humerus.
Common Pathology
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Tendinosis
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Partial-thickness tears
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Can be interstitial, articular or bursal-sided
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Full-thickness tears
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Can be incomplete or complete
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Complete retracted or complete non-retracted
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Calcific tendinopathy
Equipment
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Linear array ultrasound transducer
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27 to 22 gauge 1.5 to 2 inch needle
Common injectates:
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Local anesthetics for diagnostics
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, micronized adipose tissue, etc.)
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Avoid intratendinous corticosteroid injections.
Injectate Volume
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1 to 5 mL
Technique: Supraspinatus Tendon
Patient Position
See Fig. 16.5 .
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Seated, supine or lateral recumbent with arm in Crass or modified Crass position (shoulder extended and internally rotated, with the hand on the posterior lateral hip)
Clinician Position
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On the side of the affected shoulder, behind or in front of patient (depending on dexterity and comfort)
Transducer Position
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Long axis to the SS.
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Keeping this orientation, scan the tendon from anterior to posterior to identify locations of pathology. The tendon should also be scanned in transverse to obtain orthogonal views for an accurate assessment.
Needle Position
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In-plane, distal to proximal fibers (lateral to medial) or, alternatively, can inject proximal to distal fibers.
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Can redirect the needle to get more anterior to posterior fibers.
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Can also inject in the transverse view; can inject in-plane posterior to anterior across the SS fibers.
Target
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Pathologic aspect of SS tendon
Technique: Infraspinatus/Teres Minor Tendons via Ultrasound Guidance
Patient Position
See Fig. 16.6 .
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Seated or lateral recumbent with elbow flexed 90 degrees and shoulder internally rotated
Clinician Position
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On the side of the affected shoulder, behind patient
Transducer Position
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Long axis to the tendon, scan anterior-posterior/superior-inferior to identify pathology.
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Continue scanning inferiorly, and you will come to the small footprint of teres minor. The tendon should also be scanned in transverse to obtain orthogonal views for an accurate assessment.
Needle Position
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In-plane, distal to proximal (lateral to medial) approach or proximal to distal approach
Target
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Pathologic aspect of infraspinatus or teres minor
Technique: Subscapularis Tendon via Ultrasound Guidance
Patient Position
See Fig.16.7 .
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Lateral decubitus or supine with shoulder externally rotated (instruct patient to turn palm to ceiling)
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Sometimes easier to have patient flex elbow to 90 degrees and have assistant bedside passively externally rotate shoulder.
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Clinician Position
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On the side of the affected shoulder
Transducer Position
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Long axis to the tendon, scan superior-inferior to identify pathology
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The tendon should also be scanned in transverse to obtain orthogonal views for an accurate assessment.
Needle Position
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In-plane, distal to proximal (lateral to medial) approach
Target
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Pathologic aspect of subscapularis
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Ultrasound evolution of the rotator cuff is susceptible to anisotropic artifact due to the curved course of the tendons, especially at the insertions, and should not be mistaken for tendinosis or partial-thickness rotator cuff tear.
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The posterior aspect of the SS overlaps with the infraspinatus. The infraspinatus tendon is centrally positioned and surrounded by hypoechoic muscle that can be mistaken for a tendon tear if scanned obliquely.
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The subscapular tendon can have a varied appearance, with hyperechoic tendon fibers interposed with hypoechoic muscle fibers, and can be confused with tendinosis or partial tear.
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Orthogonal views should be used to verify pathology.
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Full Crass position can be difficult for some patients due to pain; modifying with slight shoulder extension and less internal rotation can still bring SS from under the acromion without placing excessive stress on shoulder. If modifying for diagnostic purposes, modified Crass position can result in overestimation of the size of rotator cuff tear. 17
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Injured areas of tendon may distend with injection and small aliquots of anesthetic before a regenerative procedure can help localize occult or small tears.
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Ultrasound-guided bone marrow concentrate combined with platelet products are a safe and useful alternative to conservative exercise therapy of full thickness, less than 1 cm retracted SS tendons. 18
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Utilizing a brachial plexus nerve block or suprascapular nerve block can help reduce the discomfort on part of the patient when using bone marrow concentrate or other orthobiologics.
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Patient positioning is best either supine or lateral recumbent. Sitting position risks patient falling if experiencing a vasovagal episode.
Glenohumeral Joint Capsule Ligaments
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Anterior capsule can be difficult to visualize under ultrasound in patients with larger body habitus.
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The capsular ligaments provide static stability across the glenohumeral joint.
Pertinent Anatomy
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Anterior capsule is composed of superior glenohumeral ligament (SGHL), middle glenohumeral ligament (MGHL), and anterior band of the inferior glenohumeral ligament (IGHL).
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The SGHL functions to resist inferior translation and external rotation of the humeral head in the adducted arm.
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The MGHL functions primarily to resist external rotation from 0 to 90 degrees and provides anterior stability to the moderately abducted shoulder.
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The anterior band of IGHL functions to resist anteroinferior translation.
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The superior glenohumeral and CHL were shown to be important stabilizers against inferior shoulder motion, even though the CHL is much more robust.
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The MGHL functions to resist external rotation from 0 to 90 degrees and provides anterior stability at 45 to 60 degrees abduction.
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The IGHL complex is the most important stabilizer of the joint, resisting anterior and inferior shoulder translation. The anterior band prevents anterior dislocation with the shoulder in abduction and external rotation, and is injured in anterior shoulder dislocations.
Common Pathology
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The majority (95%) of traumatic dislocation are anterior.
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Leads to chronic anterior capsular instability and, if left untreated, eventually leads to need for athroplasty.
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Internal impingement of glenohumeral joint can be a result of deficiencies of glenohumeral capsular ligaments.
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Excessive repetitive external rotation in throwing athletes (example: baseball pitchers) increases anterior capsule strain, leading to internal impingement syndrome.
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Tightness of the posterior capsule will result in glenohumeral internal rotation deficiencies (GIRDs), leading to internal impingement syndrome.
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Equipment
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Linear ultrasound transducer
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Needle size: 25 to 22-gauge 2 to 3.5-inch needle
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27 to 25 gauge 1.5 to 3 inch needle
Common injectates
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.)
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Avoid intraligamentous corticosteroids.
Injectate Volume
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1 to 3 mL per ligament
Technique: Superior Glenohumeral Ligament and Coracohumeral Ligament via Ultrasound Guidance
Patient Position
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The patient lies supine or lateral recumbent with the affected shoulder closest to the physician.
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The shoulder is slightly extended.
Clinician Position
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Side of affected shoulder
Transducer Position
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The transducer is placed over the anterosuperior shoulder transverse view of the rotator interval, with the long head biceps tendon (LHBT) at the center of image in short axis with SS and subscapularis to either side.
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The CHL is draped over the LHBT and SGHL deep to the LHBT, forming a sling around the tendon as it enters the glenohumeral joint.
Needle Position
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Out-of-plane, identify needle tip and redirecting into each structure.
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Alternatively, can inject in long axis lateral to medial approach
Target
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Inject the CHL and SGHL around the LHBT
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See Fig. 16.8
Fig. 16.8
(A) Patient and probe position. (B) Ultrasound image with targets ( asterisks ). (C) Injection. BT, Biceps tendon; CH-L , corahumeral ligament, SGHL, superior glenohumeral ligament; SSc, subscapularis tendon; SSp, supraspinatus tendon.
Technique: Middle Glenohumeral Ligament via Ultrasound Guidance
Patient position
See Fig 16.9 .
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Supine or lateral recumbent with shoulder externally rotated (instruct patient to turn palm to ceiling)
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Sometimes easier to have patient flex elbow to 90 degrees and have assistant bedside passively externally rotate shoulder.
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Clinician Position
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Side of patient
Transducer Position
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Short axis to LHBT in the bicipital groove
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As patient or assistant externally rotates the shoulder, slide transducer medial to the bicipital groove.
Needle Position
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In-plane needle visualization lateral to medial
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Out-of-plane optional, visualize needle tip just above humeral head.
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Target
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If possible, identify the anterior glenoid and corresponding labrum.
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The MGHL will be just superficial to the labrum traveling from glenoid to humeral head and deep to the subscapularis muscle.
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Inject diffusely along the MGHL
Technique: Inferior Glenohumeral Ligament via Ultrasound Guidance
Patient position
See Figs. 16.10 and 16.11 .
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The patient lies supine or lateral decubitus with the affected shoulder closest to the physician.
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The shoulder is flexed and internally rotated.
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Dorsum of the affected side is just above the patient’s head.
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Goal is to flex and internally rotate the shoulder as much as possible to move neovascular structures out of the needle trajectory.
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Clinician Position
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Side of affected shoulder
Transducer Position
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Start distal on humeral shaft in short axis and then slide proximally until the humeral shaft changes into the humeral head (circular structure).
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The IGHL appears as a hyperechoic thickening over the humeral head as you slide anterior to posterior.
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Should view the ligament in orthogonal views: transducer parallel to humerus and transverse.
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Observe adjacent neovascular structures and avoid them.
Needle Position
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Parallel to humerus view, inject in-plane: from either distal to proximal or proximal to distal.
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Choose the safest approach with regard to neovasculature.
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In the transverse view, in-plane needle approach from posterior/lateral to anterior/medial.
Target
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Inject diffusely along the IGHL fibers surrounding the humeral head.
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Injured areas will easily distend.
Pearls and Pitfalls
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When treating the IGHL, utilize Doppler flow to identify and avoid the axillary vessels that run with the axillary nerve.
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After treating the IGHL in the axilla, ensure to discard the needle before targeting other structures in the shoulder and possibly sterilize the probe.
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Propionibacterium acnes mostly colonizes the pilosebaceous follicles in the skin of the upper body, including the head, neck, shoulders, and especially the axilla. 32
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