Glenohumeral joint injection (technique)
Citation, DOI & article data
- Shoulder joint injections (technique)
- Shoulder injection (technique)
Glenohumeral joint injections (often referred to as shoulder injections ) are performed as part of a number of therapeutic and imaging procedures using a variety of approaches and modalities. The underlying principles shared by all techniques are to avoid damage to the glenoid labrum, long head of biceps tendon, surrounding neurovascular structures and articular cartilage.
On this page:
Indications
Injection into the glenohumeral joint may be necessary in the following settings:
- diagnostic and/or therapeutic corticosteroid +/- local anesthetic injection
- glenohumeral (shoulder) arthrography
- glenohumeral (shoulder) hydrodilatation
Contraindications
Anticoagulation is a relative contraindication and should be assessed in the context of the risks of ceasing anticoagulation versus the risk of hemarthrosis. It some settings it will be best to avoid arthrography entirely or consider using indirect arthrography.
ADVERTISEMENT: Supporters see fewer/no ads
Procedure
A variety of approaches, both anterior and posterior, have been described to cannulate the glenohumeral joint using a variety of modalities, most commonly fluoroscopy or ultrasound. The procedure is carried out with sterile technique, without sedation and only requires local anesthetic to skin. A 21-gauge spinal needle is typically used 4.
A normal joint will usually have a capacity of 8-15 mL. This will be reduced in adhesive capsulitis 5.
Preprocedural evaluation
Routine patient interactions are carried out (the procedure is explained to the patient, informed consent obtained, allergy and comorbidity history obtained, time-out performed including ensuring the correct side is being investigated, etc).
The shoulder needs to be exposed and skin examined for active infection.
Equipment
- sterile procedure pack, wash, gloves and gown
- local anesthetic for skin (e.g. 1%/2% lignocaine) with needle (e.g. 23 or 25 G needle) and syringe
- 21 or 22-gauge spinal needle (length depends on the size of the patient)
- syringe for injectable (this will depend on the indication - see above)
- syringe for contrast if needed (depending on indication, modality and operator preference)
- short connecting tube (optional)
- dressing
Fluoroscopic technique
Regardless of technique meticulous sterile technique and generous antiseptic prep to the skin should be applied.
Anterior approach
The patient is placed supine with the arm somewhat externally rotated (palm facing upwards). Note, excessive external rotation not only may be painful, it will also tighten the anterior capsule reducing the space anteriorly 3.
Skin entry is marked over the upper medial quadrant of the humeral head 4. This is the rotator cuff interval, avoiding the tendons of supraspinatus, subscapularis and biceps tendon 4. Alternatively, a location somewhat lower down along the humeral head can be chosen, requiring passing through the subscapularis tendon 5,6. This notwithstanding, what is critical is that the needle is lateral to the medial humeral articular edge to avoid damaging the glenoid labrum.
The needle is then introduced vertically (needle tip overlying the hub) along the axis of the x-ray beam at the marked site until articular cartilage is encountered 4.
Intra-articular position is confirmed by the introduction of a small amount of contrast that should be seen to outline the joint space and the subcoracoid recess 4.
Posterior approach
The patient is placed prone with the shoulder to be injected elevated. Imaging is then oriented to see the joint line tangentially (i.e. joint space is visualized without overlap of glenoid and humeral head) 1.
Skin entry is marked over the inferomedial aspect of the articular surface, superomedial to the anatomical neck of the humerus (the site of capsular attachment) 1.
The needle is then introduced vertically along the axis of the x-ray beam at the marked site until articular cartilage is encountered 1.
Intra-articular position is confirmed by the introduction of a small amount of contrast 1.
Ultrasound technique
Both anterior and posterior approaches (see above) can also be performed under ultrasound guidance.
CT technique
Either an anterior or posterior technique can be taken with visualization of the glenohumeral joint allowing direct placement of needle-tip position. Injection of contrast is still required to ensure an intra-articular needle tip position.
ADVERTISEMENT: Supporters see fewer/no ads
Complications
Extracapsular injection is probably the most common complication. The most serious complication is septic arthritis. Hemarthrosis is also rarely encountered.
See also
Quiz questions
References
- 1. Farmer KD, Hughes PM. MR arthrography of the shoulder: fluoroscopically guided technique using a posterior approach. (2002) AJR. American journal of roentgenology. 178 (2): 433-4. doi:10.2214/ajr.178.2.1780433 - Pubmed
- 2. Dépelteau H, Bureau NJ, Cardinal E, Aubin B, Brassard P. Arthrography of the shoulder: a simple fluoroscopically guided approach for targeting the rotator cuff interval. AJR. American journal of roentgenology. 182 (2): 329-32. doi:10.2214/ajr.182.2.1820329 - Pubmed
- 3. Jacobson JA, Lin J, Jamadar DA, Hayes CW. Aids to successful shoulder arthrography performed with a fluoroscopically guided anterior approach. Radiographics : a review publication of the Radiological Society of North America, Inc. 23 (2): 373-8; discussion 379. doi:10.1148/rg.232025706 - Pubmed
- 4. Lungu E, Moser TP. A practical guide for performing arthrography under fluoroscopic or ultrasound guidance. Insights into imaging. 6 (6): 601-10. doi:10.1007/s13244-015-0442-9 - Pubmed
- 5. Jacobson JA, Lin J, Jamadar DA, Hayes CW. Aids to successful shoulder arthrography performed with a fluoroscopically guided anterior approach. Radiographics : a review publication of the Radiological Society of North America, Inc. 23 (2): 373-8; discussion 379. doi:10.1148/rg.232025706 - Pubmed
- 6. Berná-Serna JD, Redondo MV, Martínez F, Reus M, Alonso J, Parrilla A, Campos PA. A simple technique for shoulder arthrography. (2006) Acta radiologica (Stockholm, Sweden : 1987). 47 (7): 725-9. doi:10.1080/02841850600774050 - Pubmed
Related articles: Imaging in practice
- imaging in practice
-
general radiography (adult)
- portable radiography
- chest radiography
- abdominal radiography
-
upper limb radiography
-
shoulder girdle radiography
- scapula series
-
shoulder series
- shoulder (AP view)
- shoulder (internal rotation view)
- shoulder (external rotation view)
- shoulder (superior-inferior axial view)
- shoulder (inferior-superior axial)
- shoulder (West Point view)
- shoulder (Velpeau view)
- shoulder (modified trauma axial view)
- shoulder (supine lateral view)
- shoulder (modified transthoracic supine lateral)
- shoulder (lateral scapula view)
- shoulder (AP glenoid view)
- shoulder (Garth view)
- shoulder (outlet view)
- shoulder (Stryker notch view)
- acromioclavicular joint series
-
clavicle series
- clavicle (AP view)
- clavicle (AP cephalic view)
- clavicle (oblique view)
- sternoclavicular joint series
- arm and forearm radiography
- wrist and hand radiography
- wrist series
- scaphoid series
- hand series
- thumb series
- fingers series
- rheumatology hands series
- bone age (radiograph)
-
shoulder girdle radiography
-
lower limb radiography
- pelvic girdle radiography
- thigh and leg radiography
- ankle and foot radiography
- skull radiography
-
paranasal sinus and facial bone radiography
- facial bones
- nasal bones
- zygomatic arches
- paranasal sinuses
- temporal bones
- dental radiography
- orthopantomography
- mandible
- mandible (PA view)
- mandible (PA axial view)
- mandible (AP axial view)
- mandible (oblique view)
- temporomandibular joints
- temporomandibular joint (AP axial view)
- temporomandibular joint (axiolateral view)
- temporomandibular joint (axiolateral oblique view)
-
spinal radiography
- cervical spine series
-
thoracic spine series
- thoracic spine (AP view)
- thoracic spine (lateral view)
- thoracic spine (oblique view)
- lumbar spine series
- sacrococcygeal radiography
- scoliosis radiography
-
pediatric radiography
- radiographic positioning terminology
- systematic radiographic technical evaluation (mnemonic)
- pediatric immobilization
- foreign body ingestion series (pediatric)
- foreign body inhalation series (pediatric)
- shunt series
- chest radiograph (pediatric)
- abdomen radiograph (pediatric)
- upper limb radiography (pediatric)
-
lower limb radiography (pediatric)
- pelvis radiograph (pediatric)
- femur series (pediatric)
- pediatric femur (AP view)
- pediatric femur (lateral view)
- leg length view
- knee series (pediatric)
- pediatric knee (AP view)
- pediatric knee (lateral view)
- tibia fibula series (pediatric)
- pediatric tibia fibula (AP view)
- pediatric tibia fibula (lateral view)
- pediatric tibia fibula (oblique view)
- ankle series (pediatric)
- pediatric ankle (AP view)
- pediatric ankle (mortise view)
- pediatric ankle (lateral view)
- foot series (pediatric)
- pediatric foot (DP view)
- pediatric foot (oblique view)
- pediatric foot (lateral view)
- skull radiography (pediatric)
- spine radiography (pediatric)
-
skeletal survey
-
skeletal survey (non-accidental injury)
- torso
- pediatric chest (AP erect view)
- pediatric chest (oblique ribs view)
- pediatric abdomen (AP supine view)
- pediatric spine (whole lateral view)
- upper limb (both sides)
- lower limb (both sides)
- pediatric femur (AP view)
- pediatric knee (lateral view)
- pediatric tibia fibula (AP view)
- pediatric ankle (lateral view)
- pediatric foot (DP view)
- torso
-
skeletal survey (non-accidental injury)
-
CT
- iodinated contrast media
- CT IV contrast media administration
-
CT protocol
- composite
- whole-body CT (protocol)
- CT Chest abdomen-pelvis (protocol)
- CT NCAP (neck, chest, abdomen and pelvis)
- head & neck
- chest
- abdomen and pelvis
- CT abdomen-pelvis (protocol)
- CT abdominal aorta
- CT adrenals (protocol)
- CT cholangiography (protocol)
- CT colonography (protocol)
- CT enteroclysis (protocol)
- CT enterography (protocol)
- CT gastrography (protocol)
- CT kidneys, ureters and bladder (protocol)
- CT urography (protocol)
- CT Renal mass (protocol)
- CT angiography of the splanchnic vessels (protocol)
- CT renal split bolus
- CT pancreas (protocol)
- liver
- composite
- barium studies
-
MRI
- cine imaging
-
brain
- screen protocol
- stereotaxis protocol
- tumor protocol
- stroke protocol
- infection protocol
- trauma protocol
- demyelination protocol
- epilepsy protocol
- neurodegenerative protocol
- trigeminal neuralgia protocol
- posterior fossa protocol
- temporal bone/IAM/CPA protocol
- pineal and tectal plate protocol
- pituitary gland protocol
- CSF flow
- angiographic protocols
- MRA
- circle of Willis (COW)
- carotid-vertebral system
- MRV
- MRA
- head and neck
- orbits protocol
- sinonasal tract protocol
- salivary glands protocol
- oropharynx and oral cavity protocol
- suprahyoid neck protocol
- infrahyoid neck protocol
- chest
- abdomen and pelvis
- abdomen
- liver and biliary tree
- liver protocol
- MRCP: cholangiopancreatography
- pancreas protocol
- elastography
- anus and rectum
- uterus and ovaries
- urological
- prostate cancer protocol
- bladder cancer protocol
- kidneys protocol
- musculoskeletal
-
ultrasound
- ultrasound signs
-
obstetric ultrasound
- other
- placenta
-
second trimester
- fetal biometry
- fetal morphology assessment
-
soft markers
- nuchal fold thickness
- ventriculomegaly
- absent nasal bone
- echogenic intracardiac focus
- choroid plexus cysts
- echogenic bowel
- aberrant right subclavian artery
- amnioreduction
- echogenic fetal bowel
- umbilical artery Doppler assessment
- chorionic villus sampling (CVS) and amniocentesis
- nuchal translucency
- failed early pregnancy
- subchorionic hematoma
- multiple gestations
- ectopic pregnancy
-
first trimester and early pregnancy
- gestational sac
- yolk sac
- embryo/fetus
- amnion
- chorion
- Beta-hCG levels
- gynecologic ultrasound
- vascular ultrasound
- carotids
- extremities
- mesenteric vessels
- other
- breast ultrasound
-
musculoskeletal ultrasound
- technique/artifacts
- ultrasound of arthropathies
- skin/soft tissue ultrasound
- lipoma
- parasitic infection
- other
- pediatric musculoskeletal ultrasound
- ankle/foot ultrasound
-
knee ultrasound
- Baker cyst (popliteal cyst)
- infrapatellar bursitis
- hip ultrasound
- hand ultrasound
- wrist ultrasound
- elbow ultrasound
- shoulder ultrasound
- liver ultrasound
- hyperechoic liver lesion
- sonographic halo sign
- ultrasound appearances of liver metastases
- periportal hyperechogenicity
- periportal hypoechogenicity
- generalized increase in hepatic echogenicity
- generalized reduced hepatic echogenicity
- coarsened hepatic echotexture
- starry sky appearance (ultrasound)
- normal hepatic vein Doppler
- hepatic arterial resistive index
- gallbladder ultrasound
- pancreatic ultrasound
- gastrointestinal ultrasound
- renal ultrasound
- bladder ultrasound
-
testicular and scrotal ultrasound
- other
- epididymis
- paratesticular lesions
- bilateral testicular lesion
-
unilateral testicular lesion
- testicular torsion
- orchitis
- testicular rupture
-
germ cell tumor of the testis
- testicular seminoma
-
non seminomatous germ cell tumors
- mixed germ cell tumor
- yolk sac tumor (endodermal sinus tumor)
- embryonal cell carcinoma
- choriocarcinoma
- testicular teratoma
- testicular epidermoid (teratoma with ectodermal elements only)
- burned out testis tumor
- sex cord / stromal tumors of the testis
- prostate ultrasound
- neck and thyroid ultrasound
- echocardiography
- speckle tracking echocardiography
- fetal echocardiography
- contrast-enhanced echocardiography
- epicardial echocardiography
- three dimensional (3D) echocardiography
- transesophageal echocardiography (TEE)
- transthoracic echocardiography (TTE)
- left ventricular systolic and diastolic function
- structure and morphology
- systolic function
- diastolic function
- right ventricular assessment
- right and left atria
- valvular structure and function
- mitral valve
- aortic valve
- pulmonic valve
- tricuspid valve
- hemodynamics
- pericardium
- cardiomyopathies
- congenital heart disease
- great vessels
- pediatric ultrasound
- ultrasound interventions
- ultrasound-guided biopsy
- ultrasound-guided percutaneous drainage
- ultrasound-guided musculoskeletal interventions
- joint injection
- nerve blocks
- ultrasound-guided intravenous cannulation
- contrast-enhanced ultrasound
- physics and imaging modes
- grey-scale (B-mode)
- motion mode (M-mode)
- color flow Doppler (CFD)
-
spectral Doppler
- pulsed wave Doppler (PWD)
- continuous wave Doppler (CWD)
- superb microvascular imaging (SMI)
- tissue Doppler imaging (TDI)
- nuclear medicine
-
radiation therapy
- external beam radiation therapy (EBRT)
- sealed source radiation therapy (brachytherapy)
- unsealed source radiation therapy
-
interventional
- procedure overview
- neck
- thyroid gland
- breast
- chest
- hepatobiliary
- splenic interventions
- gastrointestinal
- urogenital
- bladder
- kidney
- prostate
- musculoskeletal
-
arthrogram
- MR arthrogram
- CT arthrogram
- anesthetic arthrogram
- bone biopsy (CT-guided)
-
arthrogram
- upper limb
- lower limb
-
hip
- hip joint injection (technique)
- greater trochanteric bursa injection
- gluteus minimus/medius tendon calcific tendinopathy barbotage
- iliopsoas tendon bursa injection
- lateral cutaneous femoral nerve of the thigh injection
- piriformis injection
- common hamstrings origin injections
-
knee
- common peroneal (fibular) nerve injection
- knee joint injection
- patella tendon microtenotomy
- quadriceps tendon microtenotomy
- tibial nerve injection
-
ankle
- achilles hydrodilation & microtenotomy
- ankle joint injection
- extensor tendon sheath injection
- flexor tendon sheath injection
- os trigonum injection
- peroneal tendon sheath injection
- subtalar joint injection
- tibial nerve injection
-
foot
- calcaneocuboid joint injection
- metatarsophalangeal joint (MTPJ) injection
- naviculocuneiform joint injection
- plantar fascia microtenotomy
- subtalar joint injection
- talonavicular joint injection
- tarsometatarsal joint (TMTJ) injection
-
hip
- spine
- breast imaging
-
mammography
- breast screening
- breast imaging and the technologist
- forbidden (check) areas in mammography
-
mammography views
- craniocaudal view
- mediolateral oblique view
- additional (supplementary) views
- true lateral view
- lateromedial oblique view
- late mediolateral view
- step oblique views
- spot view
- double spot compression view
- magnification view
- exaggerated craniocaudal (axillary) view
- cleavage view
- tangential views
- caudocranial view
- bullseye CC view
- rolled CC view
- elevated craniocaudal projection
- caudal cranial projection
- 20° oblique projection
- inferomedial superolateral oblique projection
- Eklund technique
- normal breast imaging examples
-
mammography
- digital breast tomosynthesis
- breast ultrasound
- breast ductography
- breast MRI
- breast morphology
- breast intervention
Related articles: Interventional procedures
- introduction
- procedure overview
- neck
- thyroid gland
- breast
- chest
-
hepatobiliary
- liver
- biliary system
- splenic interventions
- gastrointestinal
- urogenital
- bladder
- kidney
- prostate
- musculoskeletal
-
arthrogram
- MR arthrogram
- CT arthrogram
- anesthetic arthrogram
- bone biopsy (CT-guided)
- shoulder (disambiguation)
-
elbow
- common extensor origin microtenotomy
- common flexor origin microtenotomy
- distal biceps tendon sheath injection
- elbow joint injection
- median nerve injection
- ulnar nerve injection
-
hip
- hip joint injection
- common hamstrings origin microtenotomy
- gluteus minimus/ medius tendon calcific tendinopathy barbotage
- greater trochanteric bursa injection
- iliopsoas tendon bursa injection
- lateral femoral cutaneous nerve of the thigh injection
- piriformis injection
- quadratus femoris injection
-
knee
- common peroneal (fibular) nerve injection
- knee joint injection
- patella tendon microtenotomy
- quadriceps tendon microtenotomy
- tibial nerve injection
-
ankle
- achilles hydrodilation & microtenotomy
- ankle joint injection
- extensor tendon sheath injection
- flexor tendon sheath injection
- os trigonum injection
- peroneal tendon sheath injection
- subtalar joint injection
- tibial nerve injection
-
arthrogram
- spine
- vascular