Shoulder Subacromial InjectionsNonsteroidal anti-inflammatory drugs NSAIDs and activity modification are the initial treatments to reduce the pain and inflammation. The skin is disinfected. Sterile gloves test prop t bol cycle worn, and a gauge needle is used subcaromial penetrate the skin parallel or oblique concerning the surface of the probe and 2 cm away from the probe. The needles progress is monitored in real time with ultrasonographic guidance, and the injection is performed when the tip appears corticosteroid injection for subacromial bursitis be inside the coorticosteroid. Hypoechoic fluid can be seen spreading inside the bursa while injecting.
Injection Around the Shoulder | ShoulderDoc by Prof. Lennard Funk
To determine whether lidocaine test injections would increase the success rate of corticosteroid injection for treatment of impingement syndrome. The SA group received the same amount of steroid injection into the subacromial bursa without a prior lidocaine injection. Categorical outcomes were utilized and subjects were grouped based on percentage pain relief. This was the first study to show that a lidocaine pre-injection increases the success rate of steroid injection in patients suspected of having impingement syndrome.
Shoulder impingement syndrome is a clinical syndrome that occurs when the rotator cuff becomes irritated and inflamed as it passes through the subacromial bursa.
This impingement may be accompanied by subacromial bursitis, rotator cuff tendinitis, and rotator cuff tears. Corticosteroid injection into the subacromial bursa alleviates the pain from impingement syndrome and subacromial bursitis. Variation in the efficacy of subacromial bursa injection might be due to the difficulty in identifying the pain focus. It is difficult to locate the source of pain in the shoulder because the shoulder is surrounded by many complicated structures.
Problems in the glenoid labrum and the deep surface of the rotator cuff can cause internal impingement. This internal impingement can present with symptoms similar to subacromial bursitis, and it may be misdiagnosed as subacromial bursitis [ 3 , 4 ]. Several physical examination techniques can be used to locate the source of the pain, but unfortunately, these methods have low sensitivity or specificity [ 5 , 6 ]. However, the pathologic findings do not always match the pain source because asymptomatic pathologic findings in the shoulder, such as asymptomatic subacromial bursa thickening and asymptomatic calcific tendinitis, are usually detected on the images [ 7 , 8 ].
Lidocaine is a local anesthetic commonly used in clinics and it is characterized by a rapid onset of action. Therefore, it has been used as a test material to localize the pain focus in adhesive capsulitis or lumbar facet joint syndrome [ 9 , 10 ]. We postulated that using a lidocaine injection as a test would improve the therapeutic efficacy of corticosteroid injection for shoulder pain. For example, if a lidocaine injection into the subacromial bursa does not eliminate the pain temporarily in patients suspected of having subacromial impingement syndrome, then the corticosteroid injection should be administered at other sites because the subacromial bursa is not the pain focus.
Our hypothesis was that lidocaine test injections prior to the steroid treatment would help us determine the most effective steroid injection site, and thus, they would increase the success rate of corticosteroid injections for treatment of impingement syndrome.
We recruited patients who visited our outpatient clinic for shoulder pain from February to October Among them, we selected those who were diagnosed with impingement syndrome by physical examination and US or MRI images. We made a diagnosis of impingement syndrome when the Neer and Hawkins-Kennedy tests were positive on physical examination and subacromial bursa swelling or bursal wall thickening was found on US or MRI images.
Patients who had prior shoulder surgery or who had received steroid injection less than 3 months before the study were excluded.
Patients taking oral medication for the purpose of controlling shoulder pain were asked to stop taking the medication during the study period. Only patients with a normal passive range of motion flexion, abduction, internal rotation, and external rotation in the shoulders were included in our study so as to exclude coexisting adhesive capsulitis.
We checked the acromioclavicular joint tenderness and bicipital groove tenderness to exclude acromioclavicular joint arthritis and bicipital tendinitis. Patients who were unable to describe their pain status accurately due to poor cognitive functions were excluded.
Patients with serious psychiatric disorders were also excluded. A linear probe Model No. The bicipital groove, subacromial bursa, rotator cuff tendons and muscles, acromioclavicular joint, and posterior glenoid labrum were examined through the US studies.
Patients with rotator cuff or labral tears were excluded from the study while those with subacromial bursa swelling or bursal wall thickening were included in the study. The selected patients were separated into two groups according to serial time; the LC group from January to October and the SA group from February to December Pain evoking positions were based on the maneuvers that typically caused the patient pain, but they typically included: Neers, Hawkins-Kennedy, and various range of motion maneuvers.
For the injection, patients were laid on the table in a supine position with their hands beneath their buttocks. If the pain did not decrease, patients changed their positions so that they lay on their sides with the painful shoulder pointing upwards.
The steroid injection was administered into the glenohumeral joint via a posterior approach under US guidance Figures 1B and 1D. We performed the steroid injection into the glenohumeral joint because we assumed that the impingement occurred at the glenohumeral joint rather than at the subacromial bursa. All of the patients were asked to visit the outpatient clinic at 3 weeks and 3 months after the injection to evaluate the therapeutic effect. During the second visit 3 weeks after the injection , experienced physical therapists taught the self-exercise protocols for impingement syndrome to all patients and the patients were instructed to practice the protocols by themselves.
Lidocaine or steroid injection into the subacromial bursa 1A and 1C and glenohumeral joint 1B and 1D under US guidance. The numeric rating scale NRS during daily activities was evaluated before, 3 weeks after, and 3 months after the injection. For worst-case analysis, we used the NRS data before the injection as the missing NRS data for patients lost to follow-up.
A p-value less than 0. We obtained oral informed consent from all patients, and the protocol of this study was approved by our institutional review board. A total of 2, patients visited our department for shoulder pain during the study period, and among them, patients were recruited into our study.
Average time from the onset to the study was 4. One hundred thirty-nine patients were allocated to the LC group and patients were included in the SA group. The number of males and females was Average age of the patients in the LC and SA groups was Patients with impingement syndrome were allocated to the LC and SA groups, received the corticosteroid injection and were followed up for 3 weeks and 3 months after the injection.
There was no significant difference in the initial NRS score between the two groups 6. Sixty-three patients in the LC group exhibited a positive response after lidocaine injection into the subacromial bursa, and therefore, they received triamcinolone injection at the same location. The other 76 patients in the LC group received triamcinolone injection into the glenohumeral joint because they did not exhibit a positive response after lidocaine injection. Two patients in the LC group and 4 patients in the SA group were lost to follow up at 3 weeks after the injection, whereas 58 patients in the LC group and 55 patients in the SA group were lost to follow up at 3 months after the injection.
NRS score in the LC group changed to 2. Changes in the numeric rating scale for the lidocaine test LC group and the subacromial bursa SA group are presented. There were significant differences between the LC and SA groups at 3 weeks and 3 months after the injection.
When we conducted sub-group analysis in the LC group, there was no significant difference in NRS change between patients who received the steroid injection into the subacromial bursa and patients who received the steroid injection into the glenohumeral joint. When we compared the SA group patients with the steroid injection sub-group 63 patients that received an injection into the subacromial bursa within the LC group, changes in NRS score were 2.
There was no side effect of lidocaine and triamcinolone injection in the two groups. There were no incidents related to shoulder pain during the follow-up period in all patients. In our study, we found that a lidocaine test injection prior to steroid injection increased the success rate of corticosteroid injection for treatment of impingement syndrome. Although many patients were lost to follow up at 3 months, the decrease in NRS score was likely to be maintained at 3 months in the lidocaine test group.
We used PGIC rather than the patient-reported percentage of pain reduction because the patient-reported percentage of pain reduction tends to be over-exaggerated after the steroid injection [ 16 ]. Our results for NRS changes and PGIC supported our initial assumption that identifying the steroid injection site using a lidocaine test would make the steroid injection more effective.
We believe that the subacromial bursa was not the major pain focus in 76 patients who experienced no improvement after lidocaine injection into the subacromial bursa although they were diagnosed with impingement syndrome by physical examination and US imaging. Since impingement syndrome can be diagnosed by physical examination and US imaging study with low specificity [ 8 , 17 ], our results are explainable.
The recent meta-analysis database that reports insufficient evidence in physical tests for shoulder impingement also supports our results [ 5 ]. If the lidocaine test injection into the subacromial bursa was not effective, we assumed that the pain focus was the glenohumeral joint and performed the steroid injection at this location.
However, the pain focus could be at a different site such as the subcoracoid bursa [ 18 ]. Among the 76 patients who received the steroid injection into the glenohumeral joint in the LC group, 9 patients We suspect that these patients had a pain focus at a location other than the subacromial bursa and the glenohumeral joint. However, we did not perform a second lidocaine test injection into the glenohumeral joint or the subcoracoid bursa to identify the pain focus because we wanted to prevent possible side effects such as infection or bleeding caused by too many injections.
This might have reduced the success rate of steroid injection in the LC group. This is a limitation of our study, but we believed that one lidocaine test injection was beneficial because it increased the success rate of the steroid injection.
Unfortunately, there have been no studies for assessing the adequate amount of lidocaine for selective test block into the subacromial bursa. However, this might have caused false positives or false negatives in the lidocaine test, which was a limitation of our study. The success rate of triamcinolone injection into the subacromial bursa in our study was We demonstrated that this success rate could be increased to Patients who do not respond positively to the subacromial bursa injection might have internal impingement problems including those at the labrum and synovial tissues, which can be improved by glenohumeral joint injection.
However, the study by Hanchard used cadavers for dispersion of the dye injected into the subacromial bursa and they admitted that this dispersion might not occur in the in-vivo state.
This suggests greater pain reduction and a higher success rate due to the selection of patients who were more likely to respond positively to steroid injection into the subacromial bursa by using a lidocaine test injection prior to the steroid injection. We divided two groups according to serial time, not by the randomization. However, the criteria to allocate the patients to each group were defined not arbitrarily, but by the specific time period, so we thought that selection bias which could happen in the non-randomization study was minimal.
We did not perform this study as a double-blind design because we could not do a meaningless additional lidocaine injection in the SA group. However, this might cause the observation bias, which was the limitation of our study. The drop-out rate at 3 months after the injection was extremely high in both groups If the last observation carried forward technique is used for the analysis of missing NRS data at 3 months, the change in NRS score was 3.
There is an additional limitation in our study. Future studies should be performed to use the functional scores in addition to the pain scores to better quantify the usefulness of lidocaine test injections. This was the first study to show that a lidocaine pretest injection increases the success rate of steroid injection in patients suspected of having impingement syndrome.
The study provides useful information to clinicians who treat patients with impingement syndrome or shoulder pain. We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated. Oxford University Press is a department of the University of Oxford.
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