Can a shoulder injection be performed without X-ray (radiographic) guidance?

Shoulder Injections Without X-ray Guidance

Yes, shoulder injections can be performed without X-ray guidance with comparable accuracy to image-guided techniques in most clinical scenarios. 1

Evidence on Injection Guidance Methods

Guideline Recommendations

According to the American College of Radiology (ACR) Appropriateness Criteria, both ultrasound-guided and X-ray-guided arthrocentesis of the shoulder are considered equally appropriate (both rated 9/9) for procedures such as aspiration in suspected septic arthritis 1. This indicates that while imaging guidance is valuable, neither modality (ultrasound or X-ray) demonstrates superiority over the other.

Accuracy of Non-Image Guided Injections

• Recent research shows that landmark-guided shoulder injections can achieve acceptable accuracy rates, particularly when performed by experienced clinicians:
  • A 2024 study demonstrated that anterior shoulder injections performed by shoulder specialists without image guidance achieved an 88% accuracy rate 2
  • However, the same study showed that less experienced physicians (residents) achieved only 72% accuracy 2

Comparing Image-Guided vs. Non-Image Guided Approaches

• A 2021 Cochrane systematic review found moderate-certainty evidence that ultrasound-guided injections provide little to no clinically important benefits compared to non-image-guided injections regarding:
  • Pain outcomes (15 trials)
  • Functional outcomes (14 trials)
  • Quality of life (2 trials, low-certainty evidence) 3

Clinical Considerations for Non-Image Guided Injections

Patient-Specific Factors

The accuracy of non-image guided shoulder injections may be compromised in certain clinical scenarios:

• Patients with adhesive capsulitis have 6.15 times higher odds of injection failure when performed without imaging guidance 2
• Patients with complex shoulder anatomy or previous shoulder surgery may benefit from image guidance

Injection Approach Considerations

If performing without imaging guidance, the approach matters:

• A 2021 study comparing landmark-based approaches found that an anterior approach (94% accuracy) was significantly more accurate than the posterior approach (78% accuracy) for glenohumeral injections 4

Efficacy Considerations

While landmark-guided injections can be accurate, some evidence suggests potential benefits of ultrasound guidance:

• A randomized comparative study showed significantly greater improvement in pain scores and shoulder function with ultrasound-guided injections compared to blind injections (VAS score change: 34.9 vs 7.1, p<0.001) 5

Practical Approach to Shoulder Injections

1. For routine shoulder injections in uncomplicated cases:

   • Landmark-guided injections are reasonable and cost-effective
   • Consider using an anterior approach for higher accuracy 4

2. Consider image guidance (ultrasound or X-ray) in:

   • Patients with adhesive capsulitis 2
   • Patients with complex shoulder anatomy or previous surgery
   • Cases where previous blind injections have failed 5
   • When performed by less experienced clinicians 2

3. For suspected septic arthritis:

   • Either ultrasound or X-ray guidance is appropriate (both rated 9/9 by ACR) 1
   • The choice between modalities should be based on local expertise and availability

In conclusion, while image guidance can improve accuracy in certain scenarios, the evidence suggests that properly performed landmark-guided shoulder injections remain a reasonable option for many patients, particularly when performed by experienced clinicians using appropriate anatomical landmarks.