Intra-Articular Injection of the Glenohumeral Joint—Rotator Interval Approach

Indications and Clinical Considerations

The rotator interval approach to intra-articular injection of the glenohumeral joint is useful in patients with conditions that would preclude a posterior approach (e.g., tumor, localized infection, scapular fractures, other anatomic abnormalities). Other advantages of glenohumeral joint injection using the rotator interval approach include the ability to use shorter needles to reach the intra-articular space and the avoidance of needle-induced trauma to surrounding anatomic structures. Like the anterior approach, injection of the glenohumeral joint via the rotator interval approach can be done in the sitting position, facilitating patient comfort in the presence of fractures of the clavicle, humerus, and so on. The rotator interval approach can be performed using ultrasound and fluoroscopic guidance, which will simplify the procedure and improve the accuracy of needle placement.

The shoulder joint is susceptible to the development of arthritis from a variety of conditions that all have the ability to damage the joint cartilage. Osteoarthritis of the joint is the most common form of arthritis that results in shoulder joint pain; however, rheumatoid arthritis, posttraumatic arthritis, and rotator cuff tear arthropathy are also common causes of shoulder pain secondary to arthritis. Less common causes of arthritis-induced shoulder pain include the collagen vascular diseases, infection, villonodular synovitis, and Lyme disease. Acute infectious arthritis usually is accompanied by significant systemic symptoms, including fever and malaise, and should be easily recognized by the astute clinician and treated appropriately with culture and antibiotics rather than with injection therapy. The collagen vascular diseases generally manifest as a polyarthropathy rather than a monoarthropathy limited to the shoulder joint, although shoulder pain secondary to collagen vascular disease responds exceedingly well to the intra-articular injection technique described later.

In most patients with shoulder pain secondary to osteoarthritis, rotator cuff arthropathy, and posttraumatic arthritis pain, the pain is localized around the shoulder and upper arm. Activity makes the pain worse, and rest and heat provide some relief. The pain is constant and characterized as aching and may interfere with sleep. Some patients report a grating or popping sensation with use of the joint, and crepitus may be present on physical examination.

In addition to the previously described pain, patients with arthritis of the shoulder joint often experience a gradual decrease in functional ability with decreasing shoulder range of motion, making simple everyday tasks, such as hair combing, fastening a bra, or reaching overhead, difficult. With continued disuse, muscle wasting may occur, and a frozen shoulder may develop.

Plain radiographs are indicated for all patients with shoulder pain. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and ultrasound imaging of the shoulder are indicated if a rotator cuff tear is suspected as well as to clarify the etiology of the patient’s pain and functional disability.