Causes and findings

Equipment

Anatomy

The shoulder joint is surrounded by a large capsule and the easiest and least painful approach is posteriorly, where there are no major blood vessels or nerves. An imaginary oblique line running anteriorly from the posterior angle of the acromion to the coracoid process passes through the shoulder joint. The needle follows this line, passing through deltoid, infraspinatus and posterior capsule. The end point should be the sticky feel of cartilage on the head of the humerus or the glenoid.

Technique

Comments

The less the radiation of pain and the earlier the joint is treated, the more dramatic is the relief of symptoms. If there is resistance to the injection, the needle has probably been inserted too laterally and must be repositioned more medially. Occasionally there is slight resistance when the needle passes through the capsule. Usually one injection suffices in the early stages of the condition, but if necessary more can safely be given at increasing intervals of a week, 10 days, 2 weeks, etc.; it is sometimes necessary in advanced capsulitis to give four to six injections over about 2 months. Advise the patient that a repeat dose might be needed if the symptoms are severe and gradually return as the effect of the drug wears off.

Alternative approaches

Rarely the posterior approach is not effective, so an anterior approach is used. In this case, the arm is held in slight lateral rotation and the needle inserted on the anterior surface between the coracoid process and the lesser tuberosity of the humerus, and aimed posteromedially towards the spine of the scapula. The same dose and volume is used. The disadvantages to this approach are that the patient can see the needle advancing, the flexor skin surfaces are more sensitive and there are more neurovascular structures lying on the anterior aspect of the shoulder.

Adcortyl (10 mg/ml) can be used for this injection, especially in large shoulders where more volume is required; the dose would then be 4 ml of Adcortyl with 4 ml of 1% local anaesthetic. Smaller patients may require only 30 mg of corticosteroid.

Aftercare

Patient maintains mobility with pendular and stretching exercises within the pain-free range, progressing to stronger stretching when pain is reduced. Strong passive stretching of the capsule can be given when the pain has abated. A strengthening and stabilizing programme is often required, together with postural correction.

Causes and findings

Equipment

Anatomy

The acromioclavicular joint line runs in the sagittal plane about a thumb’s width medial to the lateral edge of the acromion. The joint plane runs obliquely medially from superior to inferior and usually contains a small meniscus. Often a small step can be palpated where the acromion abuts against the clavicle, or a small V-shaped gap felt at the anterior joint margin. Passively gliding the acromion downwards on the clavicle may help in finding the joint line.

Technique

Comments

Occasionally the joint is difficult to enter; it is normally a narrow space and degenerative changes make it more so. Traction on the arm can open up the joint space and peppering of the capsule with the solution will anaesthetize it while feeling for the joint space with the needle. This will avoid giving unnecessary pain.

Alternative approach

The joint can also be injected anteriorly and horizontally at the V-shaped gap if the superior approach is difficult. The unstable or repeatedly subluxing joint can be helped by sclerosing injections or possibly surgery.

Aftercare

The patient should rest the shoulder for a week then begin gentle mobilizing exercises. Acutely inflamed joints are helped by the application of ice, taping across the joint to stabilize it and by oral pain killers.

Causes and findings

Equipment

Anatomy

The sternoclavicular joint contains a small meniscus that can sometimes be damaged and then give painful symptoms. The joint line runs obliquely laterally from superior to inferior and can be identified by palpating the joint medial to the end of the clavicle while the patient protracts and retracts the shoulder.

Technique

Comments

Although not a common lesion, this usually responds well to one infiltration.

Aftercare

Rest for a week followed by mobilization and a progressive postural and exercise regimen. Taping the joint helps stabilize it in the acute stage after trauma.

Causes and findings

Equipment

Anatomy

The bursa lies mainly under the acromion but is very variable in size and can extend distally to the insertion of deltoid. Occasionally a tender area can be palpated around the edge of the acromion. Sometimes the bursa communicates with the glenohumeral joint capsule.

Technique

Comments

In our experience, this is the most common injectable lesion seen in orthopaedic medicine (Appendix 2). Results are usually excellent; relief of pain after one injection is usual but the rehabilitation programme must be maintained. If, rarely, the symptoms persist after two injections, the shoulder should be scanned because a cuff tear might be present. In thin patients, the fluid sometimes causes visible swelling around the edge of the acromion.

Alternative approaches

There is often loculation in long-standing bursitis. In this case, resistance is felt when injecting the solution, so the needle must be fanned around under the acromion to pepper separate pockets of the bursa – the sensation is that of injecting a sponge. Occasionally, calcification occurs within the bursa and hard resistance is felt. Infiltration with a large-bore needle and local anaesthetic may help. Failing this, surgical clearance is recommended. If palpable tenderness is found either anterior or posterior to the acromion, the injection can be given at these sites.

Acute subacromial bursitis is much less common and presents with spontaneous, rapidly increasing severe pain over a few days, which may radiate down as far as the wrist. The patient is often unable to move the arm at all and sleep is very disturbed. It should be injected in the same way as above but using a smaller total volume of 2 ml with 2% lidocaine.

Aftercare

The patient must maintain retraction and depression of the shoulders and avoid elevation of the arm above shoulder level for up to 2 weeks. Taping the shoulder in retraction/depression for a few days, with postural advice, is helpful. When pain free, the patient commences resisted lateral rotation and retraction exercises, followed by strengthening of abduction. Retraining of over arm activities to avoid recurrence is essential.

Causes and findings

Equipment

Anatomy

The subscapularis tendon inserts into the medial edge of the lesser tuberosity of the humerus. It is approximately two fingers wide at its teno-osseous insertion and is a thin, fibrous structure feeling bony to palpation.

The subscapularis bursa lies deep to the tendon in front of the neck of the scapula and usually communicates with the joint capsule of the shoulder. It is invariably extremely tender to palpation even when not inflamed.

Technique

Comments

Subscapularis bursitis and tendinitis are often difficult to differentiate. The bursa is implicated if there is more pain on the scarf test than on resisted medial rotation, and if there is even more than usual tenderness to palpation.

Alternative approaches

If the bursa and tendon are inflamed together they can both be infiltrated at the same time by peppering the tendon first and then going through it to infiltrate the bursa. The total dose is increased to 30mg in total volume of 3 ml.

Aftercare

Relative rest for a week is advised, then progressive stretching and strengthening programme when pain-free. In sporting overuse injuries the cause should also be addressed.

Causes and findings

Equipment

Anatomy

The long head of biceps lies within a sheath in the bicipital groove between the greater and lesser tuberosities. It can be palpated by getting the patient to contract the muscle under the palpating finger in the groove.

Technique

Comments

This lesion is commonly diagnosed but, in our experience, is quite rare. Palpation of what is normally a tender area can lead to a misdiagnosis of this tendinopathy, when it might be pain referred from the cervical spine, shoulder joint or rotator cuff lesion.

If there is a sudden onset of pain on flexing, a distinct bulge can appear mid-humerus, indicating rupture of the long head of biceps. After the pain has subsided the patient is usually able to function normally because the short head is sufficient to take over flexion activities.

Aftercare

Advise relative rest for a week then address the causes of the lesion.

Cause and findings

Equipment

Anatomy

The infraspinatus and teres minor tendons insert together into the middle and lower facets on the posterior aspect of the greater tuberosity of the humerus. Placing the arm in 90° of flexion, full adduction and lateral rotation brings the tendons out from under the thickest portion of the deltoid and puts them under tension. The tendons run obliquely upwards and laterally and are, together, approximately three fingers wide at the teno-osseous insertion.

Technique

Alternative approaches

Usually a painful arc is present which indicates that the lesion lies at the teno-osseous junction. Occasionally there is no arc, when the lesion lies more in the body of the tendon. In this case, the needle is inserted more medially where there is often an area of tenderness. The same technique is applied.

This lesion might occur in conjunction with subacromial bursitis. If there is a possibility of a double lesion, inject the bursa first and the tendon later if symptoms persist.

Aftercare

Relative rest is advised for up to two weeks. A progressive exercise and postural correction regimen is begun when symptom-free.

Cause and findings

Equipment

Anatomy

The supraspinatus tendon inserts into the superior facet on the greater tuberosity of the humerus, which lies in a direct line with the lateral epicondyle of the elbow. A line joining the two points passes through the tendon, which is approximately the size of the middle finger at insertion.

Technique

Comments

There is much controversy about injecting tendons because of the possibility of rupture. If the patient is elderly and the cause is traumatic, an ultrasound scan should be performed to determine if there is a tear in the tendon. Deep friction and a muscle balancing regime may then be the better treatment but surgery may be advised in some cases.

Alternative approaches

Supraspinatus tendinopathy can occur on its own but is often associated with subacromial bursitis. If there is doubt about the existence of a double lesion, the bursa should be injected first. If some pain remains on resisted abduction, then the tendon can be infiltrated a week or so later.

Calcification can arise within the tendon and a hard resistance would then be felt with the needle. It is worth attempting to break up the calcification with a large-bore needle and local anaesthetic. The results are variable. If symptoms persist a surgical opinion should be sought.

Aftercare

Relative rest is advised for up to 2 weeks. A progressive exercise and postural control regimen is begun when symptom-free.

Causes and findings

Equipment

Anatomy

The suprascapular nerve passes through the suprascapular notch into the supraspinous fossa, runs laterally to curl around the neck of the spine of the scapula and ends in the infraspinous fossa. It supplies the supraspinatus and infraspinatus, and sends articular branches to the shoulder and acromioclavicular joints.

Technique

Comments

It is worth trying an injection here when intracapsular injections for shoulder capsulitis have not been successful. A small randomized trial suggests that suprascapular nerve block is a safe and effective alternative treatment for frozen shoulder in primary care⁴¹. Some clinicians advise the use of a longer-lasting anaesthetic alone or with corticosteroid. This injection might also be useful in patients with rotator cuff tears who are not fit for surgery. Symptoms of paraesthesia or burning when placing the needle indicate that it is within the nerve. Withdraw slightly before injecting.

Aftercare

Mobility at the shoulder is maintained within pain-free range. Stretching and mobilization are started when pain permits.

Causes and findings

Equipment

Anatomy

The capsule of the elbow joint contains all three articulations – the radiohumeral, radioulnar and humeroulnar joints. The posterior approach into the small gap between the top of the head of the radius and the capitulum of the humerus is the safest and easiest.

Technique

Comments

This is not a very common injection but may be useful after trauma or fracture of the radial head.

If the cause of the symptoms is one or more loose bodies within the joint, the treatment is mobilization under strong traction. If the range is improved by this but the pain persists, an injection may be considered. Adolescents with loose bodies in the joint should be referred for surgical removal.

Alternative approaches

If the joint is very degenerated, osteophytosis might be present around the joint margin, making entry with the needle more difficult. Deposition of a small amount of the solution into the capsule enables the clinician to ‘walk’ around the joint line with minimal discomfort to the patient. Some clinicians favour the posterior approach to the joint, inserting the needle at the top of the olecranon and angling obliquely distally.

Aftercare

After a couple of days the patient should start increasing range of motion within the limits of pain using gentle stretching movements, especially into flexion. Passive mobilization techniques are effective in achieving full range but should be given with care in order not to further traumatize the joint.

Causes and findings

Equipment

Anatomy

Although the biceps can be affected at any point along its length, the insertion into the radial tuberosity on the anteromedial aspect of the shaft of the radius is particularly vulnerable. A small bursa lies at this point and can be inflamed together with the tendon or on its own. The insertion of the biceps is identified by following the path of the tendon distal to the cubital crease while the patient resists elbow flexion. The patient then relaxes the muscle and the tuberosity can be palpated on the ulnar side of the radius while passively pronating and supinating the forearm. The site is always very tender to palpation, even in the normal elbow.

Technique

Comments

Differentiation between bursitis and tendonopathy is often difficult. If there is more pain on passive flexion and pronation of the elbow than on resisted flexion, together with extreme sensitivity to palpation, the bursa is more suspect.

Alternative approaches

If a double lesion is suspected, infiltrate the bursa first and reassess 1 week later. The tendon can then be injected if necessary.

Aftercare

Rest for a week before beginning graded strengthening and stretching routine, followed by addressing the cause of the overuse.

Causes and findings

Equipment

Anatomy

The bursa lies subcutaneously at the posterior aspect of the elbow and is approximately the size of a golf ball.

Technique

Comments

If swelling is present, always aspirate first. If suspicious fluid is withdrawn, infiltration should not be given until the aspirate has been investigated. Occasionally a direct blow or fall can cause haemorrhagic bursitis. In these cases, the treatment should be immediate aspiration of all blood prior to infiltration.

Aftercare

Advise relative rest for a week, then resumption of normal activities avoiding leaning on elbow.

Causes and findings

Equipment

Anatomy

Tennis elbow invariably occurs at the teno-osseous origin, or enthesis, of the common extensor tendon at the elbow. The tendon arises from the anterior facet of the lateral epicondyle, which is approximately the size of the little finger nail.

Technique

Comments

This is a very common injectable lesion. Although the teno-osseous junction is the most usual site, the lesion can occur in the body of the tendon, in the muscle belly and at the origin of the extensor carpi radialis longus. Ignore tender trigger points in the body of the tendon, present in everyone, and place the needle exactly at the very small site of the lesion. ‘Repetitive strain injury’ can include true tennis elbow but neural stretching, relaxation techniques, cervical mobilization and postural advice might be effective if the tendon is clear. One injection usually suffices but, if symptoms recur, a second injection can be given followed by the above routine ten days later.

Alternative approaches

Sclerosant injection can be used, or tenotomy may be performed on the recurrent tendon. Depigmentation and/or subcutaneous atrophy can occur in thin patients, especially those with dark skins, and they should be informed of this before giving consent. Hydrocortisone should be used if the patient is concerned about these possible side-effects.

Aftercare

The patient rests the elbow for 10 days. Any lifting must be done only with the palm facing upwards so that the flexors rather than the extensors are used; the causal activity must be avoided. When resisted extension is pain-free, two or three sessions of deep friction with a strong extension manipulation (Mill’s manipulation) are given to prevent recurrence. Stretching of the extensors and a strengthening programme is then gradually introduced. If the cause was a racket sport, the weight, handle-size and stringing of the racket should be checked; as should the technique. Continuous static positions at work should be avoided.

Causes and findings

Equipment

Anatomy

The common flexor tendon at the elbow arises from the anterior facet on the medial epicondyle. It is approximately the size of the little finger nail at its teno-osseous origin.

Technique

Comments

Occasionally the lesion occurs at the musculotendinous junction, which is invariably a very tender point. Infiltration at this point might not be as effective but deep friction can be successful. This lesion is not as common as tennis elbow and less prone to recurrence, so follow-up treatment of deep friction and manipulation do not seem to be necessary.

Aftercare

Relative rest for a week, then stretching and strengthening exercises can be started.

Causes and findings

Equipment

Anatomy

The inferior radioulnar joint is an L-shaped joint about a finger’s width in length and includes a triangular cartilage, which separates the ulna from the carpus. With the palm facing downwards, the joint line lies just medial to the bump of the end of the ulna, one-third across the wrist. The joint line is identified by gliding the ends of the radius and ulna against each other or by palpating the space between the styloid process of the ulna and the triquetral.

Technique

Comments

Tears of the cartilage are relatively common, especially after trauma such as falling on the outstretched hand, a traction injury or after Colles’ fracture. The most pain-provoking test is the scoop test – compressing the supinated wrist into ulnar deviation and scooping it in a semi-circular movement towards flexion. The patient often complains of painful clicking and occasionally the wrist locks. Mobilization helps relieve the pain but an injection can be given in the acute phase. Often an explanation of the condition and reassurance, together with advice on avoidance, is sufficient.

Aftercare

Advise rest for a week with avoidance of flexion/ulnar deviation activities. Mobilization with distraction can be effective in meniscal tears.

Causes and findings

Equipment

Anatomy

The wrist joint capsule is not continuous and has septa dividing it into separate compartments. For this reason it cannot be injected at one spot, but requires several areas of infiltration through one injection entry point.

Technique

Comments

This is a common area for injection in patients with rheumatoid arthritis. Patients with other causes such as trauma, overuse or osteoarthritis usually respond well to a short period of pain-relieving modalities, medication and rest in a splint, followed by passive and active mobilization techniques. As in all cases of trauma, fracture, especially of the scaphoid, should be eliminated.

Alternative approaches

If the joint is badly affected and swollen, it might be necessary to use a longer needle to reach all around the area, or to inject at several points.

Aftercare

The patient rests in a splint until the pain subsides and then begins gentle mobilizing exercises within the pain-free range. Wax baths can be most beneficial and the wax can be used as an exercise ball after being peeled off the hands.

Causes and findings

Equipment

Anatomy

The first metacarpal articulates with the trapezium. The easiest entry site is at the apex of the snuff-box on the dorsum of the wrist. The joint line is found by passively flexing and extending the thumb while palpating for the joint space between the two bones. Mark the entry point slightly more proximal to allow for the rounded shape of the base of the metacarpal. Be aware that the radial artery lies at the base of the snuffbox.

The distal thumb joint, and all finger joints can best be infiltrated from the medial or lateral aspect at the joint line with the digit in slight flexion.

Technique

Comments

Trapeziometacarpal joint capsulitis is a common lesion of older females and the results of infiltration are uniformly excellent. Often it is several years before a repeat injection is required, provided the patient does not grossly overuse the joint.

Alternative approaches

Infiltrating the thumb and finger joints can be difficult as osteophytosis will almost certainly be present. It is sometimes necessary to anaesthetize the capsule with some of the solution while trying to enter the joint. Gapping the side of the joint being entered also helps, and an even finer needle, such as 30G, can be used.

Aftercare

Tape the thumb using a spica technique, or tape two fingers together to splint them for a few days. Patient then begins gentle active and passive mobilizing exercise within pain-free range and is advised against overuse of the thumb or fingers. Dipping the fingers into warm wax baths and using the wax ball as an exercise tool can be beneficial.

Causes and findings

Equipment

Anatomy

Trigger finger is caused by enlargement of a nodule within the flexor tendon sheath, which then becomes inflamed and painful. It usually occurs at the joint lines where the tendon is tethered down by the ligaments and can occur in any digit but often in thumb or index finger.

Technique

Comments

This injection is invariably effective. Although the nodule usually remains, it can continue to be asymptomatic indefinitely, but recurrence can be treated with a further injection. Occasionally a slight pop is felt as the needle penetrates the nodule. When the needle is in a tendon, a rubbery resistance is felt.

Alternative approaches

Some clinicians insert the needle alone first and then ask the patient to flex the finger. If the needle moves, this proves that the correct site has been reached and the syringe may then be attached. As this involves delay and discomfort to the patient, we recommend the method above.

Aftercare

No particular restriction is placed on the patient’s activities except relative rest for a few days.

Causes and findings

Equipment

Anatomy

The abductor pollicis longus and extensor pollicis brevis usually run together in a single sheath on the radial side of the wrist. The styloid process is always tender so comparison should be made with the pain-free side. The two tendons can often be seen when the thumb is held in resisted extension, or can be palpated at the base of the metacarpal. The aim is to slide the needle between the two tendons and deposit the solution within the sheath.

Technique

Comments

Provided the wrist is not too swollen, a small sausage-shaped swelling can often be seen where the solution distends the tendon sheath.

Alternative approaches

This is an area where depigmentation or subcutaneous fat atrophy can occur, especially noticeable in dark-skinned thin females. Although recovery can take place, the results might be permanent. Patient should be warned of this possibility before giving their consent. The potential risk can be minimized by injecting with hydrocortisone.

Aftercare

The patient should rest the hand for a week with taping of the tendons. This is followed by avoidance of the provoking activity and a graded strengthening regime if necessary.

Causes and findings

Equipment

Anatomy

The flexor retinaculum of the wrist attaches to four sites: the pisiform and the scaphoid, the hook of hamate and the trapezium. It is approximately as wide as the thumb from proximal to distal and the proximal edge lies at the distal wrist crease.

The median nerve usually lies immediately under the palmaris longus tendon at the mid-point of the wrist, and medial to the flexor carpi radialis tendon. Not every patient will have a palmaris longus so ask the patient to press tip of thumb onto tip of little finger; the crease seen at mid-point of the palm points to where the median nerve should run.

Technique

Comments

No local anaesthetic is used here because the main symptom is paraesthesia, not pain, and it is not advisable to increase the pressure within the tunnel. Care should be taken to avoid inserting the needle too vertically, when it will go into bone, or too horizontally, when it will enter the retinaculum. If the patient experiences pins and needles, the needle is in the median nerve and must be withdrawn slightly and repositioned. Although one injection is often successful, recurrences do occur. Further injections can be given if some relief was obtained, but if the symptoms still recur surgery may be required.

Alternative approach

The injection can be equally well performed by inserting the needle between the median nerve and the flexor tendons, using the same dose and volume.

Aftercare

The patient rests for 1 week and then resumes normal activities. A night splint helps in the early stages after the infiltration and the patient is advised to avoid sleeping with the wrists held in full flexion – the ‘dormouse’ position.

Causes and findings

Equipment

Anatomy

The temporomandibular joint space can be palpated just in front of the ear as the patient opens and closes the mouth. A meniscus lies within the joint and the needle must be placed below this to enter the joint space. The joint can be infiltrated most easily when the jaw is held wide open. Occasionally the meniscus is torn during trauma.

Technique

Comments

It might be necessary to manoeuvre the needle about to avoid the meniscus. If the meniscus is displaced, reduction by manipulation should be attempted about 1 week after giving the injection when the inflammation has subsided. In resistant cases surgery may be necessary.

Aftercare

The patient should avoid excessive movement of the jaw such as biting on a large apple or hard food. Gentle active movements and isometric exercises are carried out. A guard to prevent grinding the teeth at night and/or the advice of an orthodontist might be helpful.