Glenohumeral Shoulder Injection Procedure
The recommended procedure for glenohumeral shoulder injection should use aseptic technique with the anterior approach, which has demonstrated superior accuracy (94%) compared to posterior approaches without the need for ultrasound guidance. 1
Preparation and Setting
- Ensure a clean, private, well-lit room with a proper examination table that can be adjusted to a flat position 2
- Gather equipment for aseptic procedure including:
- Sterile gloves
- Skin preparation materials (alcohol, iodine disinfectant, or chlorhexidine)
- Appropriate needles and syringes
- Injectable medication
- Resuscitation equipment nearby
Patient Positioning and Approach
Anterior Approach (Preferred)
- Position patient seated or supine with arm in neutral rotation
- Use the acromioclavicular joint as the anatomical landmark 1
- The anterior approach without ultrasound guidance has shown 94% accuracy compared to 78% for the posterior approach 1
- Change needles between drawing medication and injecting into the joint 2
Injection Technique
- Perform strict aseptic preparation of the injection site 2, 3
- Consider offering local anesthetic for patient comfort 2
- Options include topical anesthetics, subcutaneous infiltration, or mixing with injectate
- Insert needle using the anterior approach with the acromioclavicular joint as landmark 1
- Aspiration of synovial fluid, if present, helps confirm intra-articular needle placement 2
- Inject medication slowly
Injectable Options
For glenohumeral osteoarthritis:
- Corticosteroid injections: Evidence is insufficient to recommend for or against their use in glenohumeral osteoarthritis 2, 3
- Viscosupplementation (hyaluronic acid): May be considered as an option for glenohumeral osteoarthritis 2, 3
For adhesive capsulitis or hemiplegic shoulder pain:
- Corticosteroid mixture: Typically 1 mL of triamcinolone (40 mg/mL) with 2 mL of local anesthetic 4, 5
Accuracy Considerations
- Ultrasound guidance is optional but beneficial for shoulder injections to improve accuracy 3, 6
- Without imaging guidance, the anterior approach has demonstrated superior accuracy (64.7%) compared to posterior (45.7%) or supraclavicular (45.5%) approaches 7
- Provider experience does not significantly improve accuracy with landmark-based approaches 7
Special Considerations
- For patients with adhesive capsulitis, a multisite injection approach (targeting glenohumeral joint, posteroinferior capsule, subacromial space, posterosuperior capsule, biceps long head, and coracohumeral ligament) has shown better outcomes than single glenohumeral injection 5
- Avoid corticosteroid injections for 3 months preceding joint replacement surgery 3
- Monitor patients with diabetes for transient hyperglycemia during days 1-3 post-injection 3
Post-Injection Care
- Inform patients about potential side effects including post-injection pain flare
- Advise relative rest of the joint for 24-48 hours after injection
- Consider physical therapy as an adjunct treatment, particularly for adhesive capsulitis
Common Pitfalls to Avoid
- Failing to use proper aseptic technique, which increases infection risk
- Injecting too superficially, resulting in subcutaneous placement
- Overconfidence in injection accuracy, especially by experienced providers 7
- Not changing needles between drawing medication and performing the injection 2
The anterior approach to glenohumeral injection offers the best balance of accuracy and patient comfort when ultrasound guidance is not available, making it the preferred technique for most clinical settings.