Where are steroids injected into the shoulder?

Steroid Injection Sites in the Shoulder

Steroid injections into the shoulder are most commonly administered into the glenohumeral joint or the subacromial space, with specific anatomical landmarks used to guide accurate placement. 1, 2

Anatomical Injection Sites

Glenohumeral Joint Injection

• Anterior Approach:

  • Uses the acromioclavicular joint as the anatomical landmark
  • Higher accuracy rate (94%) compared to posterior approach (78%) 3
  • Recommended as the preferred landmark-based approach when ultrasound is not available
  • Needle is inserted into the glenohumeral joint space

• Posterior Approach:

  • Uses the acromion as the anatomical landmark
  • Less accurate than the anterior approach (78% vs 94%) 3
  • Traditionally common but may result in more misplaced injections

Subacromial Space Injection

• Injection site is beneath the acromion process
• Commonly used for conditions like subacromial bursitis and impingement syndrome
• For bursitis under the shoulder, 1 mL of betamethasone injectable suspension is typically used 2

Injection Guidance Techniques

• Landmark-Based: Using anatomical landmarks without imaging

  • Less expensive and more time-efficient
  • Lower accuracy rates compared to image-guided techniques

• Ultrasound-Guided:

  • Provides real-time visualization of needle placement
  • Higher accuracy (90% vs 76% for blind injections) 4
  • Recommended as optional but beneficial for shoulder injections 5
  • Particularly useful for glenohumeral joint injections

• Fluoroscopy-Guided:

  • Allows confirmation of proper needle placement
  • Useful for complex cases or when accuracy is critical

Dosing Guidelines

For shoulder injections, the FDA-approved dosing guidelines for betamethasone are 2:

• Large joints (shoulder): 1 mL
• Medium joints (elbow, wrist): 0.5 to 1 mL

Clinical Considerations

• Accuracy of injection placement significantly affects clinical outcomes 6
• Intra-articular corticosteroid injections provide significant short-term pain relief, typically lasting 4-8 weeks 5
• When administering injections:
  • Strict aseptic technique is mandatory to minimize infection risk
  • Local anesthetic may be mixed with the steroid for immediate pain relief
  • Avoid repeated injections due to potential long-term negative effects on joint structure 5

Important Precautions

• Avoid injections for 3 months preceding joint replacement surgery 5
• Monitor patients with diabetes for transient hyperglycemia during days 1-3 post-injection 5
• Use caution in patients on immunosuppressive therapy 5
• Physical therapy should be continued during and after injection therapy for optimal outcomes 5

While both glenohumeral and subacromial injections can be effective for shoulder conditions, the specific site should be determined based on the underlying pathology. For accuracy without ultrasound guidance, the anterior approach to the glenohumeral joint is recommended over the posterior approach.