Physiatrists’ Online Resource

 

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Injection Techniques: Upper Limbs

 

Shoulder Treatments           

Shoulder Joint

            Acromio-clavicular Joint

            Sterno-clavicular Joint

            Subacromial Bursa

            Supraspinatus Tendon

            Infraspinatus Tendon

            Subscapularis Tendon or Bursa

            Suprascapular Nerve

 

Elbow Treatments

            Elbow Joint

            Olecranon Bursa

Common Extensor Tendon

Common Flexor Tendon

Biceps Tendon Insertion

 

Wrist Treatments

Wrist Joint

Inferior Radio-Ulnar Joint

Thumb and Finger Joints

Thumb Tendons

Flexor Tendon Nodule

Carpal Tunnel

 

 

Shoulder Joint

  1. Acute or chronic capsulitis
  2. Cause:
    1. Trauma
    2. OA, RA
    3. Idiopathic
  3. Findings
    1. Pain in deltoid area radiating to the hand
    2. Painful loss of passive shoulder external and internal rotation and abduction
  4. Equipments
    1. Syringe: 5 ml
    2. Needle: 21G 1.5-2”
    3. Kenalog 30 mg
    4. Lidocaine 1% 4.25. ml
    5. Total Volume: 5 ml.
  5. Anatomy
    1. The shoulder joint is surrounded by a large capsule and the easiest and least painful approach is posteriorly, where there are no major blood vessels or nerves.
    2. An imaginary oblique line running from the posterior angle of the acromion to the coracoid process anteriorly passes through the shoulder joint. The needle follows this line passing through deltoid, infraspinatus and posterior capsule.
  6. Technique
    1. Patient sits with arm held in internal rotation across waist.
    2. Identify and mark posterior angle of acromion with thumb and coracoid process with index finger.
    3. Insert needle just below angle and push obliquely towards coracoid process.  Endpoit is when needle touches intraarticular cartilage.
    4. Introduce fluid in a bolus.
  7. Aftercare
    1. Maintenance of mobility with pendular and stretching exercises within pain-free range, with stronger stretching when pain is reduced.

 

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Acromioclavicular Joint

  1. Acute or chronic capsulitis
  2. Cause
    1. Trauma
    2. Occasionally prolonged overuse
  3. Findings
    1. Pain at point of shoulder
    2. Pain at end-range of passive shoulder cross-adduction
  4. Equipments
    1. Syringe: 1 ml
    2. Needle: 25G 0.5”
    3. Kenalog 10 mg
    4. Lidocaine 2% 0.75 ml.
    5. Total Voulme: 1 ml.
  5. Anatomy
    1. The A-C joint line runs in the sagittal plane about a thumb’s width medial to the lateral edge of the acromion.
  6. Technique
    1. Patient sits supported with arm hanging by side to slightly separate the joint surfaces.
    2. Identify lateral edge of acromion. Move medially about a thumb’s width and mark joint line.
    3. Insert needle angling medially about 30 deg. And pass through capsule.
    4. Deposit solution in bolus.
  7. Aftercare
    1. Relative rest for one week then gentle mobilizing exercises.
    2. Acutely inflamed joints are helped by the application of ice and taping to stabilize the joint.

 

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Sterno-clavicular Joint

  1. Acute or Chronic Capsulitis
  2. Cause
    1. Trauma
    2. Overuse
  3. Findings
    1. Pain over sterno-clavicular joint.
    2. Painful retraction and protraction of the shoulder
    3. Painful with full elevation of the arm
    4. Clicking
  4. Equipment
    1. Syringe: 1 ml
    2. Needle: 25G 0.5”
    3. Kenalog 10 mg
    4. Lidocaine 2% 0.75 ml
    5. Total Volume: 1 ml
  5. Anatomy
    1. The joint line runs obliquely laterally from superior to inferior and can be identified by palpating the joint medial to the end of the clavicle while the patient protracts and retracts the shoulder.
  6. Techniques
    1. Patient sits supported with arm in slight lateral rotation
    2. Identify and mark joint line
    3. Insert needle perpendicularly through joint capsule
    4. Deposit solution in bolus.
  7. Aftercare
    1. Rest for a week followed by mobilization and progressive postural and exercise regimen.

 

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Subacromial Bursa

  1. Chronic Bursitis
  2. Cause
    1. Overuse
  3. Findings
    1. Pain in deltoid area
    2. Painful passive abduction and internal rotation
    3. Painful resisted abduction and external rotation, often on release of resistance
  4. Equipment
    1. Syringe: 5 ml
    2. Needle: 23G 1.25’
    3. Kenalog 20 mg
    4. Lidocaine 1% 4.5 ml
    5. Total Volume: 5 ml
  5. Anatomy
    1. The bursa lies mainly under the acromion, but is variable in size and there may be more than one.
  6. Technique
    1. Patient sits with arm hanging by side to distract humerus from acromion.
    2. Identify and mark lateral edge of acromion
    3. Insert needle at midpoint of acromion and angle slightly upwards under acromion to full length.
    4. Slowly withdraw needle while simultaneously injecting fluid in a bolus wherever there is no resistance. Sometimes the fluid causes visible swelling around the edge of the acromion.
  7. Aftercare
    1. Relief of pain after one injection is usual but the patient must maintain retraction and depression of the shoulders and avoid elevation of the arm above shoulder level for one week. After this the patient commences resisted external rotation and retraction exercises and retraining of averarm activities in order to avoid recurrence

 

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Supraspinatus Tendon

  1. Chronic tendonitis
  2. Cause:
    1. Overuse
  3. Findings:
    1. Pain in deltoid area.
    2. Painful resisted abduction
    3. Pain ful arc on active abduction.
  4. Equipments:
    1. Syringe: 1 ml
    2. Needle: 25G 0.5”
  5. Anatomy:
    1. The greater tuberosity, into which the tendon inserts, lies in a direct line with the lateral epicondyle of the elbow. A line joining the two points passes through the tendon which is approximately the size of the middle finger at insertion into the superior facet.
  6. Technique:
    1. Patient sits supported with forearm medially rotated behind back, bringing the tendon forward, so it lies just anterior to the edge of the acromion.
    2. Identify the lateral epicondyle of the elbow, now facing anteriorly, and run finger up front of humerus to touch  anterior edge of acromion. The greater tuberosity now lies immediately anterior with tendon insertion in the hollow between the two bones. Mark this facet.
    3. Insert needle perpendicular through tendon to touch bone.
    4. Pepper solution into tendon.
  7. Aftercare:
    1. Relative rest for 1 week then progress exercise regimen and postural control when symptom-free.

 

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Infraspinatus Tendon

  1. Chronic Tendinitis
  2. Cause:
    1. Overuse
  3. Findings:
    1. Pain in deltoid area
    2. Painful resisted external rotation
    3. Painful arc on active abduction
  4. Equipments:
    1. Syringe: 2 ml
    2. Needle: 23G 1.25”
    3. Kenalog 20 mg
    4. Lidocaine 2% 1.5 ml
    5. Total Volume: 2 ml
  5. Anatomy:
    1. The infraspinatus and teres minor tendons insert together into the middle and lower facets on the posterior aspectof the greater tuberosity of the humerus. They are together approximately 3 fingers wide at the teno-osseous insertion
  6. Techniques:
    1. Patient sits with supported arm flexed to right angle (90 deg) and held in adduction and external rotation. This brings the posterior facet out from under the thickest portion of the deltoid and puts the tendon under tension running obliquely upwards and laterally.
    2. Identify posterior angle of acromion. Tendon insertion now lies 45 deg inferior and lateral in direct line with the lataral epicondyle of the elbow. Mark this spot on the two posterior facets.
    3. Insert needle at midpoint of tendons at insertion. Pass through tendon and touch bone.
    4. Pepper solution in two rows up and down into teno-osseous junction.
  7. Aftercare:
    1. Relative rest for 1 week then progressive exercise regimen and postural correction when pain-free.

 

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Subscapularis Tendon and Bursa

  1. Acute or Chronic Tendinitis or Bursitis
  2. Cause:
    1. Overuse
    2. Trauma
  3. Findings:
    1. Pain in deltoid area or anterior shoulder
    2. Pain with resisted internal rotation, with active abduction, passive external rotation and passive full horizontal adduction
  4. Equipments:
    1. Syringe: 2 ml
    2. Needle: 23G 1.25”
    3. Kenalog 10 mg for tendon and 20 mg for bursa
    4. Lidocaine 2% 0.75 ml for tendon and 1.5 ml for bursa
    5. Total Volume: 1 ml for tendon and 2 ml for bursa
  5. Anatomy:
    1. The subscapularis tendon inserts into the medial edge of the lesser tuberosity of the humerus. It is approximately 2 fingerbreadth at its teno-osseous insertion and feels bony to palpation.
    2. The subscapularis bursa lies deep to the tendon in front of the neck of the scapula and communicates with the joint capsule of the shoulder.
  6. Technique:
    1. Patient sits supported with arm by side and held in 45 deg external rotation.
    2. Identify coracoid process. Move laterally to feel small protuberance of lesser tuberosity by passively rotating arm. Mark this spot on medial aspect of tuberosity.
    3. Insert needle at midpoint of tuberosity angling slightly laterally. Touch bone at insertion.
    4. Pepper solutin into tendoninsertion or deposit bolus deep to tendon into bursa.
  7. Aftercare:
    1. Relative rest for 1 week then progressive stretching and strengthening program when pain-free.

 

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Suprascapular Nerve

  1. Acute or Chronic Capsulitis
  2. Cause:
    1. Trauma
    2. OA, RA
    3. Idiopathic
  3. Findings:
    1. Pain in deltoid area possibly radiating to the hand
    2. Painful loss passive external rotation with a hard endfeel
  4. Equipment:
    1. Syringe: 5 ml
    2. Needle: 21G 1.75”
    3. Kenalog 20 mg
    4. Lidocaine 1% 4.5 ml
    5. Total Volume: 5 ml
  5. Anatomy:
    1. The suprascapular nerve passes through the suprascapular notch into the supraspinatus fossa, passes laterally to curl around the neck of the spine of the scapula and ends in the infraspinous fossa.
    2. It supplies the supraspinatus and infraspinatus and sends articular branches to the shoulder and A-C joint.
  6. Technique:
    1. The patient sits supported with arm in neutral position.
    2. Identify mid-point of spine of scapula and mark spot one finger cephalad and one finger lateral
    3. Insert needle perpendicular to suprascapular fossa and angle slightly laterally to touch bone.
    4. Deposit solution in bolus.
  7. Aftercare:
    1. Mobility in the shoulder is maintained within pain-free range. Stretching and mobilization are started when pain permits.

 

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