Ultrasound Guided Interventional Procedures In.13

REVIEW ARTICLE
Ultrasound-Guided Interventional Procedures in

Pain Medicine
A Review of Anatomy, Sonoanatomy, and Procedures. Part III: Shoulder
Philip W.H. Peng, MBBS, FRCPC* and Peter Cheng, DO
Abstract: Application of ultrasound for musculoskeletal injections is

increasingly popular. The common targets for shoulder injection are the
subacromial subdeltoid bursa, glenohumeral joint, acromioclavicular joint,
and the long head of biceps tendon. This review describes and summarizes the anatomy and sonoanatomy relevant to the injection of these
structures. The feasibility, accuracy, and effectiveness of the injections
into and around these shoulder structures, as well as the injection techniques, are also described in detail.
(Reg Anesth Pain Med 2011;36: 592Y605)
The use of ultrasound for MSK examination and injection

is well established. Structured training programs have been developed for radiologists, rheumatologists, orthopedic surgeons,
physical medicine and rehabilitation specialists, sports medicine
physicians, and other health care professionals in Europe and
North America.6Y9 However, the use of MSK ultrasound is still
in its development phase among interventional pain specialists.
This review article was devoted to ultrasound-guided MSK injections and serves to increase the awareness and understanding
of these concepts for practicing clinicians.
METHODS
ltrasound in pain medicine (USPM) is a rapidly evolving

applied skill that allows both image-guided interventions
and diagnostic applications within the broader subspecialty of
interventional pain management. In general, the application of
USPM can be divided into 3 broad categories according to the
target tissues: peripheral, axial, and musculoskeletal (MSK)
structures (Table 1). The applications to the peripheral and axial
structures were reviewed earlier in this journal.1,2 Because of the
extensive amount of information available, the current review
focuses only on commonly performed interventions directed at
various shoulder structures, including the subacromial subdeltoid bursa (SASDB), glenohumeral joint (GHJ), acromioclavicular joint (ACJ), and the long head of biceps (LHB) tendon. The
first objective of this review was to describe and summarize the
anatomy and sonoanatomy relevant to these shoulder structures.
The second objective was to summarize the feasibility, accuracy,
and effectiveness of injections around and into these structures,
as well as the injection techniques.
Pain originating from the MSK system is one of the major
global causes of disability and one of the most common reasons
for patients to visit primary and tertiary care practitioners.3Y5
Interventional pain management is an important modality in
the multidisciplinary care of patients with MSK pain, especially
when these patients are refractory to the conservative measures.
Ultrasound-guided MSK injection is gaining popularity compared with the other imaging modalities because of its various
advantages (Table 2).
From the *Department of Anesthesia and Pain Management, University

Health Network, University of Toronto, Toronto, Ontario, Canada; and
Department of Anesthesiology, Division of Interventional Pain Management, Kaiser Permanente Hospital, Riverside, CA.
Accepted for publication August 8, 2011.
Address correspondence to: Philip W.H. Peng, MBBS, FRCPC, McL 2-405,
Department of Anesthesia, Toronto Western Hospital, 399 Bathurst St,
Toronto, Ontario, Canada M5T 2S8 (e-mail: Philip.peng@uhn.on.ca).
Dr Peng received equipment support from SonoSite Canada.
This study received institutional funding.
Copyright * 2011 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0b013e318231e068
592
We performed a literature search of the MEDLINE database

from January 1980 to February 2011 using the search terms
ultrasound, ultrasound-guided, pain management, and
different shoulder structures relevant in this review, such as
subdeltoid bursa, subacromial bursa, biceps tendons,
glenohumeral joint, and acromioclavicular joint.
ANATOMY
The shoulder is the most common region where ultrasoundguided MSK injection is applied because it is prone to injury
or attrition. Pain in the shoulder region can originate from various structures in the shoulder girdle, which is composed of
the scapula, the clavicle, and the proximal humerus, all acting as
a single biomechanical unit. From this, 3 joints (glenohumeral,
acromioclavicular, and sternoclavicular joints) and 2 gliding
planes (subacromial and scapulothoracic) provide the greatest
range of movement allowable of any joint in the body.10
Glenohumeral Joint
The GHJ is a synovial ball-and-socket joint composed of
a round humeral head and a relatively small, flat, pear-shaped
glenoid fossa. The glenoid cavity is widened and deepened by the
presence of a fibrocartilaginous rim, the glenoid labrum (Fig. 1).
Because only one third of the humeral head is covered by the
glenoid cavity, and the capsule is lax and thin, it allows the
shoulder the widest range of movement of all joints but confers
the shoulders inherent instability, making it susceptible to subluxation and dislocation.11Y13
The joint capsule is attached medially to the margin of
the glenoid cavity extending to the base of the coracoid process
and laterally to the anatomic neck of the humerus (Fig. 1). The
synovial membrane lines the capsule on its deep surface and
overlies the LHB tendon. From there, 3 recesses are formed: the
biceps tendon sheath anteriorly, the subscapularis recess medially, and the axillary pouch inferiorly (Fig. 2). The implication of
the biceps tendon sheath will be discussed later in the rotator cuff
interval. The stability of the GHJ is maintained by the ligaments,
the rotator cuff tendons, and the deltoid muscle. The glenohumeral ligaments (GHLs) are 3 weak bands of fibrous tissue
(superior GHL [SGHL], middle GHL, and inferior GHL) that
strengthen the front of the capsule. The coracohumeral ligament
Regional Anesthesia and Pain Medicine
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Volume 36, Number 6, November-December 2011
Copyright 2011 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Comparison Among 3 Applications of USPM
Target structures
Ultrasound
visualization of
target structures
Conventional or
existing technique
for injection
Level of difficulty*
Peripheral
Axial
MSK
Peripheral
soft tissue
Good to
moderate
Spine
Poor to
moderate
Bursa/joint/
tendon
Good to
moderate
Mostly blind
Image guided
IYII
IIYIII
Mostly
blind
I
*The level of difficulty was based on a meeting and survey of the

founding members of USPM Special Interest Group (SIG) in Innsbruck,
May 2009. The level of difficulty was appraised based on 4 criteria and
was classified into level I (basic), level II (intermediate), and level III
(advanced).
Adapted with permission from usra.ca.
(CHL) is a strong band of fibrous tissue arising from the coracoid process and inserting onto the greater and lesser tuberosities
to reinforce the capsule (Fig. 1).
Ultrasound in Pain Medicine/Shoulder
ment, a weak ligament formed by the superficial fibers of the

SSC tendon.
The rotator cuff interval is a triangular space that occupies
the area between the tendons of SSC and SS and the base of the
coracoid process.17,18 It is roofed by the rotator interval capsule, which is principally made up of the CHL (Figs. 3 and 5)19
and contains the tendon of the LHB tendon and the SGHL. The
combination of the CHL and SGHL has a complex relationship
to the LHB tendon, which act together to prevent the tendon
from subluxing in the anterior direction.19 The rotator cuff interval is a space where the GHJ synovial lining extends around
the biceps tendon and where the arthroscope enters the GHJ to
avoid damaging the cuff tendons.20,21 Thus, this is an entry site
in which an interventionist can access the GHJ.
Subacromial Subdeltoid Bursa

The SASDB, the largest bursa in the body, is located inferior to the acromion, the CAL, and the deltoid muscle. It overlies
the superior aspect of the SS tendon.10,22 It also extends anteriorly to cover the bicipital groove and medially to the coracoid
process (subcoracoid bursa). The lateral border may reach approximately 3 cm below the greater tuberosity.23 The main role
of the SASDB is to minimize attrition of the cuff against the
coracoacromial arch (acromion and CAL) and the deltoid muscle during movements of the arm.
Rotator Cuff
There are 4 rotator cuff muscles: subscapularis (SSC),
supraspinatus (SS), infraspinatus (IS), and teres minor (TMi)
muscles. The rotator cuff is a tight layer of tendons around the
GHJ on the anterior (SSC), superior (SS), and posterior (IS and
TMi) aspects of the shoulder (Fig. 3).14 It plays an important
role in stabilizing the humeral head in the shallow glenoid
fossa during the movement of the arm.
The SSC muscle originates from the anterior surface of the
scapular fossa and converges into a flat and wide tendon that
inserts onto the lesser tuberosity. The superficial fibers of the
tendon overlay the bicipital groove and reach the greater tuberosity, merging with the CHL and transverse humeral ligament.
The SS muscle originates from the SS fossa of the scapula,
passes beneath the acromion and coracoacromial ligament (CAL),
and inserts on the upper facet of the greater tuberosity (Fig. 4A).
The IS muscle originates from the IS fossa and converts into a
wide tendon that inserts on the greater tuberosity just posterior
and inferior to the SS tendon (Fig. 4B). The interface between IS
and SS is not well defined because the fibers of both tendons
intertwine, forming a continuum.10 The TMi muscles originates
from a narrow strip on the lateral border of the scapula and inserts onto the most caudal segment of the greater tuberosity, just
posterior and inferior to the IS muscle.
Biceps Tendon and Rotator Cuff Interval

The LHB tendon arises from the supraglenoid tubercle and
the superior labrum. The proximal part of this tendon is intraarticular but extrasynovial.15,16 The tendon travels obliquely
over the anterosuperior aspect of the humeral head and exits the
joint within the bicipital groove, formed by the greater and lesser
tuberosities on the lateral and medial sides, respectively (Fig. 5A).
In the bicipital groove, an extension of the synovial lining of the
GHJ invests the LHB tendon down to approximately 3 to 4 cm
beyond the distal end of the groove (Fig. 2). Thus, fluid distension within the sheath usually reflects an underlying GHJ disease
rather than tendon pathology. In the bicipital groove, the LHB
tendon is accompanied by the ascending branch of the anterior
circumflex artery and is covered by the transverse humeral liga* 2011 American Society of Regional Anesthesia and Pain Medicine
Acromioclavicular Joint
The ACJ is a small synovial joint located between the
concave medial end of the acromion and the convex lateral end
of the clavicle. It has a limited range of motion. The articular
surfaces are made up of hyaline cartilage and are separated by a
wedge-shaped fibrocartilaginous disk either partly or completely
(Fig. 6). The capsule of the ACJ is attached to the articular
margins and is reinforced by the superior, inferior, anterior, and
posterior acromioclavicular ligaments.24,25 Caudally, it also receives fibers from the CAL, which blends with the undersurface
of the ACJ. The coracoclavicular ligament, composed of the
conoid and trapezoid ligaments, anchors the lateral aspect of the
clavicle to the coracoid process (Fig. 1). Because the ACJ slopes
inferomedially, resulting in overriding of the clavicle on the
acromion, the coracoclavicular ligament plays a crucial role for
the vertical stability of the ACJ.24 The inferior surface of the joint
TABLE 2. Comparison of the 3 Common Imaging Modalities

for Pain Management Intervention
Soft tissue visualization

Radiation risk
Cost
Portability
Infrastructure
Real-time guidance
Bone imaging
Deep structures imaging
Fluoroscopy
CT Scan
Ultrasound
None to poor
+-++*
+++-++++
+
++
+
Excellent
Reliable
Excellent
++
+++++
j
++++
j
Excellent
Reliable
Good
j
++-+++
++-+++
j
+
Poor-good
Unreliable
*The amount of radiation increases with the use of real-time and

digital subtraction angiography.
The cost is variable depending on the models and the institution
pricing.
Reprinted with permission from usra.ca.
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FIGURE 1. Glenohumeral joint showing various ligaments and the joint capsule. The anterior capsule is reinforced by the superior,
middle, and inferior GHL. The insert shows the articular surface, the glenoid process, and the labrum. Reprinted with permission
from usra.ca.
is in direct contact with the subacromial bursa and rotator cuff

and may play a role in the development of the impingement
syndrome (Fig. 6).
SONOANATOMY
Biceps Tendon and Rotator Cuff Interval
The LHB tendon is examined, with the patient sitting with
the arm placed in neutral or slight internal rotation position, the
elbow bent, and the palm facing up (Fig. 7A). A high-frequency
linear probe is used. Approximately at the level of coracoid
process, a short-axis view of the humerus reveals the greater and
lesser tuberosities and the bicipital groove where the LHB tendon is found. The greater tuberosity has a rounder look, whereas
the lesser tuberosity assumes a pointed shape (Fig. 7A). Tilting
of the probe is important (Fig. 7B), as the echogenicity of the
biceps tendon in this short-axis view is dependent on the angle
of the probe position (anisotropy). Doppler imaging of the area
reveals the ascending branch of the anterior circumflex artery,
which is usually on the lateral side of the tendon. In the bicipital
groove, the tendon is invested by its synovial sheath, and the
effusion at this level should be noted.
The LHB tendon runs a superomedial course and enters the
GHJ through the rotator cuff interval. To obtain a short-axis scan
FIGURE 2. The drawing of 3 main recesses of the joint (left): (A) the biceps tendon sheath, (B) the axillary pouch, (C) the subscapular
recess, and the corresponding radiographic (arthrogram) appearance (right). Reprinted with permission from usra.ca.
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Supraspinatus Tendon and Subacromial

Subdeltoid Bursa
The long-axis view of the SS tendon is obtained with the
medial aspect of the probe over the lateral part of the acromion
(Fig. 8A). The intraarticular portion of the LHB tendon runs
parallel to the SS tendon and can be used as a reference. With the
arm in neutral position, only the distal portion of the SS tendon can be seen as a convex beak-like structure attached to the
greater tuberosity. Dynamic assessment of subacromial impingement can be assessed, with the patient abducting the arm while in
internal rotation. With this maneuver, the SS tendon can be seen
passing deep to the coracoacromial arch.
To visualize the SASDB, a modified Crass position (patients arm extended posteriorly with the palm on the superior
aspect of the iliac wing) is recommended26,27 to provide a more
complete visualization of the tendon (Fig. 8B). A high-frequency
linear probe is placed in the long axis of the SS tendon, which
is parallel to the intraarticular portion of the LHB tendon. With
this scan, the deltoid muscle, SS tendon, and acromion can be
seen as well. Under normal circumstances, the synovial lining of
the SASDB cannot be visualized, but its presence can be estimated from the peribursal fat in between the deltoid muscle and
SS tendon and the use of dynamic scanning (Fig. 8A).
FIGURE 3. A schematic diagram showing the arrangement of the
4 rotator cuff muscles: subscapularis, SS, IS, and TMi. Reprinted
with permission from usra.ca.
of the LHB tendon, the orientation of the probe needs to be

adjusted accordingly (Fig. 7C). In this interval, the SS and SSC
tendons are on the lateral and medial sides, respectively. The
CHL appears as a thick hyperechoic band over the LHB tendon,
and the joint capsule is seen as a thin hypoechoic layer arising
from the deep edge of the SS tendon and intervening between the
ligament and the LHB tendon (Fig. 7C). The optimal scan at this
level is obtained by extension of the arm, which causes maximal
opening of the rotator cuff interval, stretches the LHB tendon
against the humeral head, and tightens the CHL. In the distal
portion of the rotator cuff interval, the SGHL and CHL form an
anterior sling around the anterior and medial aspects of the LHB
tendon, which is responsible for stability of LHB tendon at the
entrance of intertubercular groove (Fig. 5).
Glenohumeral Joint
The GHJ is best examined on transverse scan by placing the
transducer over the IS tendon. The patient is placed in the sitting
or lateral position, with the ipsilateral arm touching the contralateral shoulder (Fig. 9A). A linear probe is typically used, with
the exception of patients of very high body mass index, and the
probe is placed in the long axis of the IS tendon caudal to the
scapular spine (Fig. 9A). With this probe position, the posterior
part of the humeral head, glenoid process, and labrum are visualized. Medial to the GHJ, the spinoglenoid notch is usually
visualized (Fig. 9B). The suprascapular nerve, accompanied by
suprascapular artery, curves around this notch to supply the IS
muscle in the IS fossa. A paralabral cyst associated with labral
tear can be found in this notch.
The joint can be simply reviewed with a high-frequency
linear probe over the joint in the coronal plane. The hypoechoic
FIGURE 4. A, Anterior view of the shoulder showing the subscapularis and SS muscles. The anterior portion of the deltoid muscle was
reflected to show the underlying rotator cuff muscle. B, Posterior view of the shoulder to show the IS and TMi muscle. The posterior
portion of the deltoid muscle was partially removed to show the underlying muscle. Reprinted with permission from usra.ca.
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FIGURE 5. A, The anterosuperior view showing the rotator cuff interval, which is a triangular space between the tendons of subscapularis
(anterior) and SS (posterior) muscles and the base of the coracoid process. The roof is the CHL (ghosted) and the contents are the
LHB tendon (blue) and SGHL (green). B, The cut-out of the rotator cuff interval to show the content. The SGHL, a focal thickening of the
GHJ capsule, runs anterior to the tendon of the LHB initially (position a). The SGHL maintains a close relationship with the LHB tendon
and subsequently inserts into a small depression above the lesser tuberosity (position b), contributing to the biceps reflection pulley
(position c) to prevent the dislocation of the LHB tendon. Reprinted with permission from usra.ca.
joint space is seen between the hyperechoic ends of the acromion

and the distal clavicle, which may not appear at the same level in
16% of patients because of the variable obliquity of the joint
(Fig. 10).28 In a young healthy patient, a fibrocartilaginous disk
is usually seen as a slightly hyperechoic wedge-shaped structure
attached to the superior joint capsule and is mobile in its location,
depending on the arm position. The superior acromioclavicular
ligament is a hyperechoic fibrillar structure abutting the bony
surfaces of the joint.
An os acromiale is an accessory bone of the acromion that
derives from the nonfused epiphysis of the anterior part of the
acromion. The prevalence is approximately 8% and is bilateral in
one third of the cases.29 Although os acromiale is usually an
incidental finding during the scanning of ACJ, it can be a potential cause for anterosuperior impingement of the SS tendon.
Ultrasound scan shows well-defined cortical discontinuity on the
superior aspect of the acromion, often mimicking a double ACJ.
INJECTION TECHNIQUES FOR

SPECIFIC JOINT/BURSA
Overview
The main indication for ACJ injection is osteoarthritis of
this joint.30 The ACJ is a complex gliding synovial joint that
allows 3 types of movement: gliding, hinge-like, and rotation
movement. It is believed that the rotational motion, shear stress,
and high compressive force from the surrounding muscles
contribute to degenerative process of the joint.31,32 Osteoarthritis
of the ACJ is a common source of shoulder pain that is often
neglected by clinicians and researchers because of the higher
prevalence of rotator cuff pathology. The proper diagnosis of
ACJ osteoarthritis requires a thorough physical examination,
plain-film radiograph, and a diagnostic local anesthetic injection, which has been well reviewed elsewhere.24
Efficacy
FIGURE 6. The ACJ is a synovial joint with the articular surfaces

separated by a wedge-shaped fibrocartilaginous disk (asterisk).
The inferior surface of the joint is in direct contact with the
subacromial bursa and SS muscle and may play a role in the
development of the impingement syndrome. Reprinted
with permission from usra.ca.
596
Whereas the diagnostic role of ACJ injection is widely accepted,30 the role of steroid injection is less certain. Literature
search revealed 4 case series.33Y36 All supported the role of shortterm relief following ACJ steroid injection. In a retrospective
case series, 27 patients with isolated ACJ arthritis received steroid injections with landmark-based technique.35 Significant
pain relief and function improvement were achieved in 25 of
27 patients, with a mean duration of improvement of 20 days
(range, 2 hrs to 3 months). In another study, 18 patients with
isolated unilateral ACJ arthropathy were prospectively studied
2 weeks after the ACJ injections were performed under fluoroscopic guidance.36 All patients had pain relief at 2 weeks, with
mean pain score decrease from 7 of 10 to 3.6 of 10 (range, 2Y10
and 0Y8, respectively). The average duration of pain relief was
14.3 weeks (range, 8Y24 weeks). Bain et al33 performed ACJ
steroid injection in 44 patients with confirmation of needle placement with fluoroscopy, and the patients were followed up for an
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FIGURE 7. A, Ultrasound image showing the presence of LHB tendon (asterisk) within the bicipital groove. The insert shows the position of
the patient and the linear ultrasound probe. Note that the LHB tendon appears hyperechoic. B, Ultrasound image similar to A with a
different tilt of the ultrasound probe. The image illustrates the anisotropy with the LHB tendon (asterisk) changed from a hyperechoic to
a hypoechoic structure. The insert shows the position of the probe and the corresponding anatomic structures underneath. C, By
moving the ultrasound probe more proximally along the orientation of the LGH tendon, a view of rotator cuff interval is shown.
The LHB tendon (asterisk) is always hyperechoic at this level and sandwiched between the SS tendon laterally and subscapularis tendon
medially. The CHL (arrowheads) forms the roof of the interval. The insert on the left shows the orientation and position of the probe, and
the insert on the right shows the probe position and the structures underneath it. GT indicates greater tuberosity; LT, lesser tuberosity;
SC, subscapularis. Reprinted with permission from usra.ca.
average duration of 42 months. Approximately 14% resulted in

more than 3 months of pain relief. Hossain et al34 studied ACJ
steroid injections in 25 shoulders from 20 patients in a prospective
5-year follow-up. They used the Constant score, which is a composite score of pain and function (total score of 100 points with
15 points in pain assessment), and found the patients continued
to improve after 6 months. The average Constant score was significantly better at 5 years than that of preinjection level, with
more than 20 points improvement in 72% of the shoulders in
the final assessment. No randomized controlled study so far has
been published to confirm the effectiveness of ACJ injection.
was confirmed with dissection, landmark-based techniques were

only 40% to 66% accurate, whereas the accuracy was 100% with
fluoroscopy guidance.37Y39 In clinical studies where fluoroscopy
was used as the validation tool, the accuracy of landmark-based
techniques ranged between 39% and 50%.33,40 With the use of
ultrasound, the accuracy was high (95%Y100%) in cadaver studies.38,41 With a landmark-based technique, the accuracy did not
differ significantly with different levels of experience (specialist,
resident, or student).39,41
Accuracy of Landmark-Based Versus

Ultrasound-Guided Techniques
The patient position can be either in sitting (chair with back

support) or supine position. The arm should be in the neutral
position, as the deep joint space is the widest at this position.42 A
linear probe with high frequency is used because the structures
The literature supporting the use of image-guided injection is robust. In cadaveric study where the accuracy of injection
Ultrasound-Guided Injection Technique
FIGURE 8. A, Ultrasound image of the SASDB. The SS tendon is seen attached laterally onto the greater tuberosity of the humeral head
(H). The insert on the left shows the position of the patient and the ultrasound probe; the one on the right shows the probe and the
structures underneath. The deltoid muscle shows the underlying SS muscle. B, Ultrasound image of the SS tendon when the arm is put in
the modified Crass position. Note that the portion of the SS tendon lateral to the acromion process is significantly increased by this
maneuver. The insert shows the position of the modified Crass position. H indicates humeral head; D, deltoid muscle. Line arrows outline
the peribursal fat of the SASDB. Reprinted with permission from usra.ca.
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FIGURE 9. Ultrasound image of the posterior GHJ. The glenoid process and humeral head both appear as hyperechoic structures
with anechoic shadow. The insert on the top shows the position of the patient and the ultrasound probe, whereas the one below shows
the probe position and the structures underneath. B, Ultrasound image of the spinoglenoid notch by moving the ultrasound probe
slightly medially. The insert shows the position of the probe and the spinoglenoid notch, as well as the suprascapular neurovascular bundle.
H indicates humeral head; GP, glenoid process; SSN and SSA, suprascapular nerve and artery (line arrows in ultrasound image); SGN,
spinoglenoid notch (arrowheads). *Glenoid labrum. 0Articular cartilage of the humeral head. Reprinted with permission from usra.ca.
are superficial. The probe is placed over the medial side of

acromion in line with the clavicle. The ACJ can be visualized,
with the capsule covering the 2 hyperechoic structures (acromion
and clavicle). In young patients, the fibrocartilage can be seen
interposing the ACJ (Fig. 11).
Both out-of-plane and in-plane techniques have been described, but the authors preferred technique is out-of-plane as
the joint space is very superficial. The needle should be directed
almost parallel to the probe. Because the distance from the capsule to the deep joint space is approximately 4.1 T 0.9 mm,28
overzealous insertion of the needle can result in puncturing the
deep capsule and entering the subacromial space. The volume of
injectate is usually 2 mL, and a successful injection is indicated
by the elevation of capsule and widening of the joint space under
real-time scanning.
LHB Tendon
Overview
The main indication for injection around the LHB tendon
is biceps tendinopathy, which refers to a spectrum of pathology
ranging from inflammatory tendinitis to degenerative tendinosis.16 Inflammation of the LHB tendon within the bicipital
groove (primary biceps tendinitis) is uncommon.43 The vast majority of biceps tendinitis is accompanied by rotator cuff tear or
a SLAP (superior labrum anterior to posterior) lesion, as the
sheath of the LHB tendon is an extension of the synovium of the
GHJ and is closely associated with the rotator cuff (secondary
biceps tendinitis). A patient with biceps tendinitis presents with
anterior shoulder pain and tenderness over the bicipital groove.
Ultrasound is a useful tool that can reliably diagnose complete
rupture, subluxation, or dislocation of the LHB tendon but is not
reliable for detecting intraarticular partial-thickness tears (overall
specificity, 97%; sensitivity, 49%).44 Magnetic resonance arthrography is the preferred method for detecting intraarticular pathology of the biceps tendon.45
Efficacy
Despite the fact that steroid injection into the tendon sheath
is part of the recommended nonsurgical management (in addition to rest, nonsteroidal anti-inflammatory drug, and physical
therapy) described in multiple reviews, no studies have been
published on efficacy.15,16,46 The LHB tendon is certainly a pain
generator in the anterior aspect of the shoulder receiving both
sensory and sympathetic innervations.47 Selective injections may
further aid diagnosis of shoulder pathology associated with LHB
tendinitis.48
FIGURE 10. Ultrasound image of the ACJ. The upper insert shows
the position of the probe and the patient, and the lower insert
shows the position of the probe and the structures underneath.
A indicates acromion process; C, clavicle. *Wedge shape
fibrocartilaginous disk. Arrowheads point to the superior joint
capsule. Reprinted with permission from usra.ca.
598

To date, no comparative study on the accuracy between
landmark-based and ultrasound-guided techniques has been published. However, ultrasound-guided injection allows visualization
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or thawing phase of gradual return of motion, which usually

lasts 5 to 24 months.54,55 Conservative therapy is the mainstay of
management, which includes rest, analgesia, active and passive
mobilization, physiotherapy, and GHJ injection. It is important to highlight that the natural course of a frozen shoulder is
usually self-limiting. It is a disease that improves over an 18- to
24-month period.56 Therefore, the role of intervention is symptom relief and facilitation of rehabilitation.
Efficacy
FIGURE 11. The insert shows the position of the ultrasound probe
and the needle with the out-of-plane technique. The corresponding
ultrasound image shows the ACJ with the image of the needle
(solid arrow). The arrows outline the superior joint capsule.
Reprinted with permission from usra.ca.
of the anterior circumflex artery and the LHB tendon and thus
potentially avoids unintentional puncture of these structures.

The patient is placed in the sitting position with a back support. A high-frequency linear probe is used. The ultrasound probe
is placed over the bicipital groove (approximately midway between the clavicle and anterior axillary fold) to reveal the shortaxis view of the LHB tendon. A color Doppler scan is used to
locate the anterior circumflex artery. An out-of-plane approach is
the authors preferred method, with a 25-gauge needle inserted
from the medial side through the transverse humeral ligament
(Fig. 12). The total volume of injectate is 4 mL with 10 to 20 mg
of methylprednisolone diluted in local anesthetic. A well-directed
injection will show the local anesthetic surrounding the LHB
tendons at the bicipital groove.
Glenohumeral Joint
The use of intraarticular corticosteroid injections for shoulder disorders and shoulder pain has been the subject of multiple systematic reviews published between 1996 and 2007.57Y61
Some reviews examined shoulder disorders and shoulder pain as
a whole without interpreting their results on the basis of a specific diagnosis.57,59,60 The other reviews combined the results of
trials that used single and multiple injections in their treatment
of adhesive capsulitis.59,61 The most recent systematic review,
published in 2007, specifically examined the results of trials that
performed multiple injections of corticosteroids for adhesive
capsulitis.62 They included 9 randomized controlled trials, and
4 studies were rated as high quality. Three high-quality studies
showed a beneficial effect for the use of multiple corticosteroid
injections for adhesive capsulitis with outcome measures of pain
reduction, improved function, and increased range of shoulder
movement. They concluded that multiple injections were beneficial until 16 weeks from the date of the first injection. In terms
of multiple injections, their review supported that up to 3 injections were beneficial, but there was limited evidence that 4
to 6 injections were beneficial. The role of GHJ injection as part
of the conservative therapies for adhesive capsulitis needs to be
emphasized. Intraarticular steroid injection has been shown to
produce significant reduction in pain and disability after treatment with corticosteroid injections plus exercise versus exercise
alone.63
Although there is some evidence to support the use of intraarticular steroid injection in adhesive capsulitis, the role in the
conservative management of GHJ arthrosis is unclear. There are
no studies specifically addressing the efficacy in GHJ arthrosis.52 A recent practice guideline from the American Academy of
Overview
The main indication for GHJ injection is glenohumeral arthrosis and adhesive capsulitis. Glenohumeral arthrosis is characterized by progressive and irreversible articular destruction and
frequent involvement of the surrounding soft tissues.49 The exact
prevalence is not well documented.50 Primary osteoarthritis is
uncommon, and most of the causes of chondral damage are secondary to trauma, instability, postsurgical arthrosis, avascular
necrosis, inflammatory arthropathy, osteochondritis dissecans,
chondrolysis, and iatrogenic injury.50,51 In patients with shoulder
pain, glenohumeral arthrosis is an uncommon cause of pain compared with other more common pathologic conditions of the
shoulder. Thus, glenohumeral arthrosis is a diagnosis of shoulder pain by exclusion.50,51 Assessment with clinical examination and radiologic imaging has been discussed in a few excellent
reviews.50Y53
Adhesive capsulitis (frozen shoulder) is the other indication
for GHJ injection. The prevalence in the general population is
approximately 2% but increases with age and with the presence
of diabetes mellitus, hyperthyroidism, and hypertriglyceridemia.54
The condition is characterized by 3 phases: a painful phase lasting 3 to 8 months followed by an adhesive phase of progressive
stiffness, typically lasting 4 to 6 months, and the final resolution
FIGURE 12. The insert shows the position of the ultrasound

probe and the needle with the out-of-plane technique. The local
anesthetic is seen surrounding the bicep tendons in the bicipital
groove (line arrows). The black arrowhead points to the anterior
circumflex artery. GT indicates greater tuberosity; LT, lesser
tuberosity. Reprinted with permission from usra.ca.
599
Peng and Cheng
Orthopedic Surgery found no evidence to support or refute the

use of intraarticular corticosteroid injection for the treatment of
GHJ arthrosis.64 Systematic review of steroid injections for osteoarthritis of the knee demonstrated modest pain relief 2 to
3 weeks after injection, but there was no benefit over placebo at
any time point beyond 4 weeks.65 The analgesic benefit from
GHJ steroid injection, if any, is likely short term.
Apart from steroid, hyaluronic acid has been used for GHJ
arthrosis. Hyaluronic acid, a large-molecular-weight glycosaminoglycan, is a constituent of synovial fluid in normal and osteoarthritic joints and is widely used for the treatment of osteoarthritis
of the knee.66 Despite the considerable ongoing controversy regarding its efficacy, cost-effectiveness, and benefit-to-risk ratio,
the intraarticular injection of hyaluronan is recommended in 8 of
9 existing guidelines as a useful therapeutic modality for treating patients with osteoarthritis of the knee.65 A recent large,
randomized controlled trial,67 supported by the drug company that
produced the hyaluronan, investigated the effects of 5 weekly
and 3 weekly intraarticular injections of hyaluronan on a mixed
population of patients with persistent shoulder pain (GHJ osteoarthritis, rotator cuff tear, and/or adhesive capsulitis). There was a
significant placebo effect shown in the placebo group, but both
active treatment groups demonstrated significant long-term analgesic effects (913 weeks). However, in the subanalysis when
only the patients with GHJ osteoarthritis with or without other
shoulder pathology were included in the analysis, both of these
treatment groups were superior to placebo groups in pain relief
in almost all time measurements (weeks 7, 9, 17, and 26). This
lent support for use of the hyaluronan in the GHJ osteoarthritis
patient. The treatment was well tolerated by the patients.

Although many practitioners use a landmark-based technique, the use of image guidance (ultrasound or fluoroscopy) is
also very popular. In general, the validation studies can be divided into cadaveric and clinical studies. The validation methods
to confirm the placement of the injectate are cadaver dissection,
x-ray/fluoroscopy, and magnetic resonance imaging (MRI).
For the landmark-based technique, the overall success rates
of the validation studies range from 27% to 100%.68Y75 In
contrast, the success rates of the ultrasound-guided studies were
all 100%, with the exception of 2 studies.76Y84 In a study, the
success rate was 97%, with failure in one patient due to obesity
and the presence of vasovagal response.78 The authors attributed
the failure to the thick subcutaneous soft tissues and difficulty in
obtaining good visualization of the deep tissues with a superficial probe. In another study, 2 approaches (anterior and posterior) with ultrasound-guided injection were used, although
anterior approach was used in 87% (118/135 patients) of the
patients.82 Not surprisingly, the success rate of the more prevalent approach (anterior) was 95% (118 patients), whereas the rate
was 41% for the posterior approach (27 patients). An interesting
comparison study was conducted examining the ultrasoundguided approach and landmark-based (conventional) approach
in various joint interventions.85 The ultrasound-guided injections were all performed by a rheumatology trainee (9 months in
rheumatology program with 8 sessions of MSK ultrasound training), and the conventional approach was all performed by 9 rheumatology consultants with a median of 9 years of experience.
The accuracy rates were 63% and 40% for the ultrasound and
conventional groups, respectively. Despite the contrast in experience, the trainee achieved a better accuracy, which was associated with better pain relief at the sixth week.
600
&
Radiologic guidance provides excellent accuracy but exposes the patients to radiation.86Y90 Direct comparison between
ultrasound-guided and fluoroscopy-guided injections performed
by experienced radiologists had been investigated with excellent
accuracy in both groups (100%).86,87 Although both techniques
achieved the same success rate, ultrasound-guided technique
managed with higher first-attempt rate, less time spent, and
lower patient discomfort.87

Ultrasound-guided injections of the GHJ have been successfully demonstrated, irrespective of the approaches (anterior
or posterior). The posterior approach has been advocated as the
preferred approach because of the presence of fewer stabilizers
(such as GHL), absence of important articular structures (such
as capsulolabral complex), and less extravasation.78 Rotator cuff
interval has been recently described with the theoretical advantages of avoiding the anterior stabilizers and articular structures.81 All 3 approaches are described:
& Posterior approach. The patient can be in either sitting or
semiprone position, with the ipsilateral hand crossing the chest.
A linear probe is sufficient for most patients, except those with
very high body mass index, in which a low-frequency curve
probe is used. The scapular spine is palpated, and the ultrasound probe is placed just caudal and parallel to the lateral end
of the spine. With this position, the IS muscle, humeral head,
posterior glenoid rim, and labrum are revealed (Fig. 13A). A
20- or 22-gauge needle is inserted in-plane from the lateral
aspect of the probe and directed between the free edge of the
labrum and the hypoechoic articular cartilage of the humeral
head. With the injection of normal saline, the posterior joint
capsule is seen displaced. If one encounters resistance on injection, the bevel of the needle can be rotated, or the needle
can be withdrawn for a small distance.
& Anterior approach. The patient is put in supine position, with
the arm externally rotated. A low-frequency curve probe is
used in a muscular or obese patient. The probe is placed caudal
and parallel to the acromion, with the medial part covering the
coracoid process. With this position, the humeral head, SC
muscle, and coracoid process are revealed (Fig. 13 B). A 20or 22-gauge needle is inserted in-plane from the lateral side
of the probe aiming at the medial border of the humeral
head. The beveled side of the needle is adjacent to the humeral
head to facilitate the entry of the injectate. Correct position of
the needle tip results in the injectate flowing in the direction
of the subscapular recess and joint space.
& Rotator cuff interval. The patient is placed in supine position,
with the arm in neutral position. A linear probe is placed above
the bicipital groove, showing the transverse view of the LGB
tendon. With the probe in this position, the LHB, SS, and SC
tendons, SGHL, and CHL are revealed (Fig. 7C). The authors
prefer an out-of-plane technique to direct the needle into the
GHJ through the space on either side of LHB tendon.
Subacromial Subdeltoid Bursa

Overview
Shoulder pain is one of the common complaints to physicians in general practice, accounting for 11 to 12 per 1000 consultations,90 and subacromial impingement syndrome accounts
for the most common diagnosis.91 The indication for SASBD
injection is subacromial impingement syndrome, which covers
a constellation of conditions: partial- and full-thickness rotator
cuff tear and rotator cuff tendinopathy.92
&
FIGURE 13. A, Posterior approach to the GHJ. The insert (left upper) shows the position of the ultrasound probe and the needle with
in-plane technique. The corresponding ultrasound image (right) is shown with the line representing the needle path, which was directed
between the free edge of the labrum (*) and the hypoechoic articular cartilage (&) of the humeral head (H). G indicates glenoid. Insert
in the lower left shows the anatomic drawing of the ultrasound image. B, Anterior approach to the GHJ. The insert (left upper) shows
the position of the ultrasound probe and the needle with in-plane technique. The corresponding ultrasound image (right) is shown
with the line representing the needle path, which was inserted from the lateral side of the probe aiming at the medial border of
the humeral head (H). CP indicates coracoid process. *Subscapularis tendon. Insert in the lower left shows the anatomic drawing of
the ultrasound image. Reprinted with permission from usra.ca.
The rotator cuff tear can be articular sided, bursal sided, or

intratendinous, and the incidence increases with age.93,94 Rotator
cuff tendinopathy is a generic term without etiologic, biochemical, or histologic implications and is used to describe pathology
in and pain arising from a tendon.22 The common presentations
of patients with rotator cuff disease are pain and stiffness. Pain
is the predominant symptom, often most troubling at night and
with overhead activities. Partial tendon lesions are often much
more painful than full-thickness tears.95 The natural history of
partial-thickness tears of the rotator cuff is not completely elucidated, but there is a substantial body of circumstantial evidence
to suggest that most partial tears do not heal on their own and that
most of these tears progress to become larger rather than smaller
with time.96 Initially, these tears should be managed with rest,
activity modification, and nonsteroidal anti-inflammatory drugs.
Physical therapy for range of motion should then begin, with the
goal of regaining any motion lost because of capsular contractures.97 Although there is a paucity of reliable reports on the
clinical outcome of conservative treatment of partial tears, most
patients will improve with conservative measures over 6 months;
some continue to improve for up to 18 months.96 In patients
without response to the initial conservative therapy or with severe shoulder pain, SASDB injection can be considered.
subacromial steroid injections in rotator cuff disease. Their conclusion was that subacromial steroid injection is not efficacious
in the treatment of rotator cuff disease. It is important to note that
the injection techniques included in those 9 studies were all
blind injection, with the exception of 1 study in which x-ray
confirmation was performed in a portion of the patients. The
accuracy of x-rayYguided SASDB injection will be discussed
in the following section.
In a practical clinical setting, the subacromial injection is
usually performed in a multimodal approach with physiotherapy
or a rehabilitation protocol. A recent large, pragmatic, randomized controlled trial showed that the subacromial steroid injection decreased pain and improved functional outcome at 1 and
6 weeks, and there was no difference compared with exercise
alone at 3 and 6 months.102 The absence of long-term efficacy
is not uncommon for interventions of common MSK problems.
In examining results from recent high-quality randomized controlled trials for common MSK disorders, Foster et al103 found
no or very small differences in the effectiveness of different
approaches when based on long-term outcomes (6Y12 months).
This has been exemplified by the various shoulder injection
techniques described in the previous sections.
Efficacy

There are multiple reviews on the efficacy of SASDB injections for rotator cuff disease.58Y60,98Y101 Because of different
methodologies and inclusion criteria, the results of those reviews vary. One review incorporated a study that included an
injectable nonsteroidal anti-inflammatory medication among
other trials assessing the efficacy of steroid injections.101 Another included articles that either did not specifically address
rotator cuff pathology or had critical methodological flaws.98
Two other reviews appraised the efficacy of steroid injection for
several shoulder conditions.59,60 The Cochrane review was updated only until 2003.58 The systematic review performed by
Koester et al100 is the most recent review that included 9 randomized controlled trials specifically appraising the use of
The accuracy of the blind approach has been investigated

in a number of studies. With the exception of the study by Rutten
et al104 (which showed 100% success rate), the success rate
ranged from 29% to 70% in all clinical studies68,105Y109 and 70%
to 91% in cadaver studies.37,110,111 Various approaches for the
blind injection have been described (posterior, anterolateral, and
lateral), but there are no differences in their accuracy rates.105,108,111
The experience and confidence of the practitioners did not influence the accuracy rate. In studies where the blind procedures
were performed by very experienced orthopedic surgeons and
shoulder specialists, the confidence correlation (the accuracy rate
when the practitioners were very confident that they were accurate) ranged from 42% to 66%.105,109
601
Peng and Cheng
The imaging methods used for validation were mostly by xray,69,107,109 although MRI105,112 and ultrasound104 were also used.
Mathews and Glousman111 found that x-ray was an unreliable
method in confirming the location of contrast in the subacromial
space when the result was validated with cadaver dissection.
Ultrasound-guided injection was validated with MRI in one
study, and the accuracy was 100%.112 The use of the ultrasoundimaging technique in the diagnosis of the rotator cuff disease
has been extensively investigated, and the reliability is comparable with that from MRI.112Y115
With the landmark-based approach, the injectate was
found in deltoid muscle, SS tendon, SC muscle, GHJ, and
ACJ.37,105Y107,111 The accurate location of steroid in the
SASDB correlated with superior outcome in the short
term106,108 and in the intermediate term (2Y6 weeks).69,106 There
are 3 studies comparing the pain and functional outcome between the ultrasound-guided injection and blind injection groups
without validating the location of the injectate in the blind
groups.116Y118 Hashiuchi et al117 found a better pain score in the
ultrasound group at 30 minutes, and Ucuncu et al118 showed superior pain and functional outcome at 6 weeks in the ultrasound
group, whereas Chen et al did not demonstrate a difference.116

The patient can be placed either in the supine or sitting
position, with the ipsilateral arm in the modified Crass position
(the palmar surface of the hand touching the buttock). A highfrequency linear probe is placed with the medial end over the
acromion and the orientation perpendicular to the coracoacromial arch (Fig. 14). With this position, the SASDB is outlined by
the peribursal fat between the deltoid muscle and SS tendon. An
in-plane approach is the authors preferred approach, with the
needle inserted from lateral to medial direction. In some individuals with slim build, the probe can be better stabilized by
turning the probe 90 degrees. The needle can be inserted in-plane
&
from anterior to posterior direction (Fig. 14). Forty milligrams of

methylprednisolone or triamcinolone mixed with 4 to 6 mL of
local anesthetics may be injected.
CONCLUSIONS
Application of ultrasound for shoulder injection is increasingly popular. Ultrasonography allows accurate localization
of the various target structures for shoulder injections and realtime guidance of the needle insertion. A good understanding of
the anatomy and sonoanatomy is of paramount importance in
performing the ultrasound-guided injections.
ACKNOWLEDGMENTS
The authors thank Qing Huang for her exceptional medical
drawings and Alex Yeung and Cyrus Tse for their assistance with
the illustration and photography.
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REVIEW ARTICLE

Ultrasound-Guided Interventional Procedures in

Abstract: Application of ultrasound for musculoskeletal injections is

The use of ultrasound for MSK examination and injection

ltrasound in pain medicine (USPM) is a rapidly evolving

From the *Department of Anesthesia and Pain Management, University

We performed a literature search of the MEDLINE database

Regional Anesthesia and Pain Medicine

Volume 36, Number 6, November-December 2011

Regional Anesthesia and Pain Medicine

Volume 36, Number 6, November-December 2011

TABLE 1. Comparison Among 3 Applications of USPM

*The level of difficulty was based on a meeting and survey of the

Ultrasound in Pain Medicine/Shoulder

ment, a weak ligament formed by the superficial fibers of the

Subacromial Subdeltoid Bursa

Biceps Tendon and Rotator Cuff Interval

TABLE 2. Comparison of the 3 Common Imaging Modalities

Soft tissue visualization

*The amount of radiation increases with the use of real-time and

Peng and Cheng

Regional Anesthesia and Pain Medicine

Volume 36, Number 6, November-December 2011

is in direct contact with the subacromial bursa and rotator cuff

* 2011 American Society of Regional Anesthesia and Pain Medicine

Regional Anesthesia and Pain Medicine

Volume 36, Number 6, November-December 2011

Ultrasound in Pain Medicine/Shoulder

Supraspinatus Tendon and Subacromial

of the LHB tendon, the orientation of the probe needs to be

Peng and Cheng

Regional Anesthesia and Pain Medicine

Volume 36, Number 6, November-December 2011

joint space is seen between the hyperechoic ends of the acromion

INJECTION TECHNIQUES FOR

FIGURE 6. The ACJ is a synovial joint with the articular surfaces

Regional Anesthesia and Pain Medicine

Volume 36, Number 6, November-December 2011

Ultrasound in Pain Medicine/Shoulder

average duration of 42 months. Approximately 14% resulted in

was confirmed with dissection, landmark-based techniques were

Accuracy of Landmark-Based Versus

The patient position can be either in sitting (chair with back

Ultrasound-Guided Injection Technique

Peng and Cheng

Regional Anesthesia and Pain Medicine

Volume 36, Number 6, November-December 2011

are superficial. The probe is placed over the medial side of

Accuracy of Landmark-Based Versus

Regional Anesthesia and Pain Medicine

Volume 36, Number 6, November-December 2011

Ultrasound in Pain Medicine/Shoulder

or thawing phase of gradual return of motion, which usually

Ultrasound-Guided Injection Technique

FIGURE 12. The insert shows the position of the ultrasound

Peng and Cheng

Regional Anesthesia and Pain Medicine

Orthopedic Surgery found no evidence to support or refute the

Accuracy of Landmark-Based Versus

Volume 36, Number 6, November-December 2011

Ultrasound-Guided Injection Technique

Subacromial Subdeltoid Bursa

Regional Anesthesia and Pain Medicine