How to administer an intra-articular injection to the shoulder joint?

From the Guidelines

I strongly advise against attempting to inject a shoulder without proper medical training and authorization, as it should only be performed by qualified healthcare professionals such as physicians, orthopedic specialists, or trained nurse practitioners. Shoulder injections typically involve corticosteroids (like methylprednisolone, triamcinolone, or betamethasone) combined with local anesthetics (like lidocaine) to reduce inflammation and pain in conditions such as rotator cuff tendinitis, bursitis, or arthritis. The procedure requires sterile technique, proper anatomical knowledge, and appropriate equipment including the correct needle size (typically 21-25 gauge, 1.5-2 inches long).

According to the study by 1, the use of injectable viscosupplementation is an option when treating patients with glenohumeral osteoarthritis, with patients receiving three Hylan G-F 20 (Synvisc; Genzyme, Cambridge, MA) injections weekly for 3 weeks. However, the level of evidence is IV, and the recommendation grade is C. On the other hand, the study by 1 states that there is no evidence to support or refute the use of intra-articular corticosteroid injection for the treatment of OA of the shoulder.

Given the lack of strong evidence for corticosteroid injections, as noted in 1, and considering the potential risks associated with improper injection technique, such as infection, nerve damage, tendon rupture, or vascular injury, it is crucial to prioritize caution. If you're experiencing shoulder pain, consult with a healthcare provider who can properly diagnose your condition and determine if an injection is appropriate, using imaging guidance like ultrasound to ensure accurate placement of medication into the specific targeted area of the shoulder joint or surrounding tissues.

Some key considerations for healthcare professionals performing shoulder injections include:

• Using sterile technique to minimize the risk of infection
• Having proper anatomical knowledge to accurately target the affected area
• Selecting the appropriate equipment, including the correct needle size
• Considering the use of imaging guidance, such as ultrasound, to ensure accurate placement of medication
• Weighing the potential benefits and risks of different types of injections, including corticosteroids and viscosupplementation, based on the individual patient's condition and medical history.

From the FDA Drug Label

For treatment of joints, the usual intra-articular injection technique should be followed If an excessive amount of synovial fluid is present in the joint, some, but not all, should be aspirated to aid in the relief of pain and to prevent undue dilution of the steroid. With intra-articular administration, prior use of a local anesthetic may often be desirable Care should be taken with this kind of injection, particularly in the deltoid region, to avoid injecting the suspension into the tissues surrounding the site, since this may lead to tissue atrophy.

To inject a shoulder, intra-articular injection technique should be used. The steps include:

• Aspirating some of the synovial fluid if it's excessive
• Using a local anesthetic if desired
• Injecting the suspension into the joint, avoiding the surrounding tissues to prevent tissue atrophy 2

From the Research

Injection Techniques

• The proper technique for injecting the shoulder region is essential for effective outcomes 3
• Indications for glenohumeral joint injection include osteoarthritis, adhesive capsulitis, and rheumatoid arthritis 3
• Subacromial injections are useful for a range of conditions including adhesive capsulitis, subdeltoid bursitis, impingement syndrome, and rotator cuff tendinosis 3

Pharmaceutical Choices

• The choice and quantity of pharmaceuticals used for injection are crucial for effective outcomes 3
• Intra-articular hyaluronic acid (HA) has been compared to intra-articular triamcinolone hexacetonide in inflammatory knee osteoarthritis, with HA showing potential as a useful additional therapy 4
• Triamcinolone acetonide-hyaluronic acid conjugates have been developed for rheumatoid arthritis treatments, with potential for selective targeting and reduced osteoporosis effect 5

Treatment Outcomes

• Intra-articular hyaluronic acid (IAHA) has been shown to improve synovial fluid lubrication, reduce proinflammatory cytokines, and modulate nociceptive pathways in osteoarthritis 6
• IAHA has been found to be a multifaceted therapeutic approach, bridging symptomatic relief and regenerative strategies in osteoarthritis management 6
• A combination of cross-linked hyaluronic acid and triamcinolone hexacetonide has been shown to improve pain at six months in patients with mild to moderate hip osteoarthritis 7