Intra-Articular Injection of the Glenohumeral Joint—Transcoracoacromial Approach

Indications and Clinical Considerations

The transcoracoacromial approach to intra-articular injection of the glenohumeral joint is useful in patients with conditions that would preclude an anterior or posterior approach (e.g., tumor, localized infection, scapular fractures, other anatomic abnormalities, when radiographic guidance is not available). Although success using anatomic landmarks without radiographic guidance is approximately 95%, the transcoracoacromial approach can be performed using fluoroscopic guidance, which may improve the accuracy of needle placement at the expense of radiation exposure.

The shoulder joint is susceptible to developing 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. 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. The pain 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.