Subacromial bursal injection
Damage and inflamtion in the subacromial bursa and the rotator cuff tendons within the subacromial space can cause impingement syndrome and rotator cuff disorders.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and activity modification are the initial treatments to reduce the pain and inflammation. Subacromial corticosteroid injection is reserved for patients with no response to initial treatment.
- Symptomatic subacromial impingement syndrome
- Rotator cuff disorder
- adhesive capsulitis
Infection/cellulitis of the overlying skin, osteomyelitis of the adjacent bone and bacteremia are absolute contraindications.
Allergic reaction to disinfectants and local anesthetics, more than 3-4 corticosteroid injections per patient per year, poorly controlled diabetes, coagulopathy and glaucoma are relative contraindications.
The skin is disinfected. sterile gloves are worn and a 21-27 Gauge needle is used to penetrate the skin parallel or oblique in relation to the surface of the probe and 2 cm away from the probe. The needles progress is monitored in real time with the US image and the injection is performed when the tip appears to be inside the bursa. Hyperechoic fluid can be seen spreading inside the bursa while injecting. The thinner the needle the more difficult it would be to identify the needle and to perform the injection.
A dose of corticosteroid (0.5 ml of dexamethasone 4mg/1 ml) with local anesthetic (1-1.5 ml of Bupivacaine 0.5%) can be used for analgesic effect.
Positioning/room set up
US guided corticosteroid injections into the subacromial-subdeltoid bursal space are carried out with the patient sitting on a chair with his/her back turned to the physician. Lateral approach is the most frequently used approach in which the long axis of the supraspinatus is parellel to the probe. The appropriate position of the shoulder is identified with ultrasound (The thickest part of the bursa or the area with more fluid accumulation in the bursa), the patient is asked to stay still and keep the position.
- Sterile Gauze
- Sterile gloves
- Skin disinfectant
- 21 to 27 gauge long needles.
- Local anesthetic. (1-1.5 ml of Bupivacaine 0.5%)
- Corticosteroids. (0.5 ml of dexamethasone 4mg/1 ml)
Lateral approach is the most frequently used approach in which the long axis of the supraspinatus is parellel to the probe and the needle is inserted parallel or oblique in relation to the probe and 2 cm away form the probe to avoid the sterile neeld contact with the probe.