Poster 224 Indirect Ultrasound Guidance Increased Accuracy of the Glenohumeral Joint Injection Using the Superior Approach-A Cadaveric Study of Injection Accuracy

Abstract

To investigate whether or not indirect ultrasound guidance could increase the accuracy of the glenohumeral joint injection using the superior approach.
Twelve shoulders from 7 adult cadavers were anatomically dissected after a dye injection had been performed, while the cadavers were in the supine position. Before the injection, a clinician determined the injection point using the ultrasound and the more internal axial arm rotation was compared to how it was positioned in a previous study. Injection confidence scores and injection accuracy scores were rated.
The clinician's confidence score was high in 92% (11 of 12 shoulders) and the injection accuracy scores were 100% (12 of 12 shoulders). The long heads of the biceps tendons were not penetrated.
Indirect ultrasound guidance and positioning shoulder adducted at 10° and internally rotated at 60°-70° during the superior glenohumeral joint injection would be an effective method to avoid damage to the long head of biceps tendons and to produce a highly accurate injection.

Full text

Indirect Ultrasound Guidance Increased
Accuracy of the Glenohumeral Injection Using
the Superior Approach: A Cadaveric Study of
Injection Accuracy
Joon Sung Kim, MD, Min-Wook Kim, MD, Dong Yoon Park, MD
Department of Physical Medicine and Rehabilitation, St. Vincent’s Hospital,
The Catholic University of Korea College of Medicine, Suwon, Korea
Objective To investigate whether or not indirect ultrasound guidance could increase the accuracy of the
glenohumeral joint injection using the superior approach.
Methods Twelve shoulders from 7 adult cadavers were anatomically dissected after a dye injection had been
performed, while the cadavers were in the supine position. Before the injection, a clinician determined the
injection point using the ultrasound and the more internal axial arm rotation was compared to how it was
positioned in a previous study. Injection confidence scores and injection accuracy scores were rated.
Results The clinician’s confidence score was high in 92% (11 of 12 shoulders) and the injection accuracy scores
were 100% (12 of 12 shoulders). The long heads of the biceps tendons were not penetrated.
Conclusion Indirect ultrasound guidance and positioning shoulder adducted at 10° and internally rotated at 60°—
70° during the superior glenohumeral joint injection would be an effective method to avoid damage to the long
head of biceps tendons and to produce a highly accurate injection.
Keywords Shoulder, Injections, Ultrasound, Superior, Cadaver
Annals of Rehabilitation Medicine
Original Article
Ann Rehabil Med 2013;37(2):202-207
pISSN: 2234-0645 • eISSN: 2234-0653
http://dx.doi.org/10.5535/arm.2013.37.2.202
INTRODUCTION
Injections are frequently made to the glenohumeral
joint as part of treatment for adhesive capsulitis. We re-
ported high accuracy of glenohumeral joint injections
using a superior approach based on a previous study.
However, that approach risked penetrating to the long
head of the biceps brachii tendon [1].
Recently, ultrasound has been used to increase the ac-
curacy of the needle placement of intra-articular injec-
tions. There are 2 methods to approach the needle target,
the indirect technique and the direct technique. In the
indirect technique, an ultrasound is used to confirm the
puncture site and the location of the target ; however this
does not serve as a guide to advance the needle. Using
the direct technique, the needle advancement and target
Received May 4, 2012; Accepted September 13, 2012
Corresponding author: Dong Yoon Park
Dep artme nt of Phys ical Medi cine and Reha bilit ation, St. Vincent ’s
Hospital, The Catholic University of Korea College of Medicine, 93
Jungbu-daero, Paldal-gu, Suwon 442-723, Korea
Tel: +82-31-249-7650, Fax: +82-31-251-4481, E-mail: dyfree@naver.com
This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/3.0) which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original work is
properly cited.
Copyright © 2013 by Korean Academy of Rehabilitation Medicine

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are seen in real time under direct ultrasound control. The
long head of the biceps tendon can be traced by using
the ultrasound from the proximal site to just distal to the
subacromial space.
The long head of the biceps tendon is affected depen-
dent upon its location by rotating the arm externally or
internally. The adducted and internally rotated arm posi-
tion would be expected to prevent injury of that tendon
from the needle tip during glenohumeral joint injection.
The purpose of this study is to prove that adducted and
internally rotated shoulder position would improve accu-
racy of injection and prevent biceps tendon injury during
indirect, ultrasound-guided glenohumeral joint injec-
tion.
MATERIALS AND METHODS
Included in this study were 12 shoulders from 7 cadav-
ers, whose relatives consented to their use for research
purposes. Six of the shoulders used were from 4 formalin-
fixed cadavers and the other shoulders were from fresh
cadavers.
The cadavers were supine, and their elbows were flexed
90° and shoulders were positioned at 10° adduction and
at 60°—70° internal rotation, so that their hands were lo-
cated on their abdomen (Fig. 1). This position is selected
so that the needle does not damage the long head tendon
of the biceps brachii. Before the injection was performed,
ultrasonographic examination (HD11 XE ultrasound sys-
tem; Philips Healthcare, Eindhoven, The Netherlands) of
the shoulder was performed to identify the location of bi-
ceps brachii tendon by the clinician who was to perform
the injection. The tendon had been traced from the distal
aspect of bicipital groove to the proximal side by keep-
ing the probe perpendicular to the axis of biceps tendon
(Fig. 2). One mL of dye (blue ink) was injected into the
glenohumeral joint using 1.5-inch 21-gauge needle. One
experienced clinician performed the injection procedure.
After the acromioclavicular joint was palpated, the site 5
mm lateral to just anterior to the aspect of the acromio-
clavicular joint was selected as the needle entry point.
After the needle was inserted through the entry point, it
was advanced in a 20° lateral and a 20° dorsal direction.
When the resistance was felt at the tip of needle, we ap-
plied a gentle passive internal and external rotation to
Fig. 1. The cadaver’s hand is located on his/her abdo-
men. In this position, the elbow was flexed 90°, the shoul-
der was positioned at 10° of adduction and at 60°—70° of
internal rotation. The arrow indicates the injection on
point.
Fig. 2. In the transverse view of ultrasonography, the long head of biceps tendon (arrow) is seen in the bicipital groove
level (A) and the more proximal level (B). The tendon adheres to the superior margin of the glenoid and is located be-
side the CO at the coracoid process level (C). GT, greater tubercle of humeral head; CO, coracoid process.

Joon Sung Kim, et al.
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the shoulder. If the tip of the needle showed concurred
movement to this motion, we pulled the needle slightly
back, and then injected the dye.
A confidence score was rated according to clinician’s
opinion (Table 1). After the scoring, the tissues were
carefully dissected to access to the joint to where the dye
could be found. The needle and shoulder position were
maintained during dissection to prevent needle displace-
ment. Following the dissection, placement of the tip of
the needle and dye were observed to determine whether
the injected material had reached the intra-articular
space and the long head of biceps brachii tendon has
injured by the needle. Then, an injection accuracy score
was determined (Table 2).
Table 1. Confidence score
Confidence (score) Criteria
Inaccurate (1) Perception of hardness of the bi-
ceps tendon during injection after
needle retraction
Perception of high resistance during
injection after needle retraction
Observation of skin swelling after
injection
Clinician failed to feel the needle tip
touch the humeral head
Unclear (2) Unclear
Accurate (3) None of all above
Table 2. Accuracy score
Degree Accuracy
1 Miss
2 Correct and another site
3 Correct site only
Fig. 3. Blue dye is seen in the glenohumeral joint cavity.
The blue needle (A) was inserted through the anterolat-
eral side of the acromioclavicular joint and is located on
the lateral side of the long head of biceps brachii tendon
(arrow). The yellow needle (B) is the landmark of the an-
terior acromioclavicular joint.
Table 3. Summary of twelve shoulders
Cadaver
no.
Shoulder
no. Sex Age
(yr) Side Fixed
type
Confidence
score
Dye in
GH space
Dye in
SASD bursa
Biceps tendon
injury
Accuracy
score
1 1 F 93 R Formalin 3 Present Absent No 3
2 L Formalin 3 Present Present No 2 (SASD bursa)
2 3 M 77 L Formalin 3 Present Present No 2 (SASD bursa)
3 4 F 78 L Formalin 3 Present Absent No 3
4 5 M 69 R Formalin 3 Present Absent No 3
6 L Formalin 3 Present Absent No 3
5 7 M 74 R Fresh 3 Present Absent No 3
8 L Fresh 1 Present Absent No 3
6 9 F 77 R Fresh 3 Present Absent No 3
10 L Fresh 3 Present Absent No 3
7 11 M 80 R Fresh 3 Present Absent No 3
12 L Fresh 3 Present Absent No 3
R, right; L, left; GH, glenohumeral; SASD, subacromial-subdeltoid.

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RESULTS
The average age of the cadavers in life was 78 years
(range, 69 to 93 years). Three of the cadavers were female
and the other 4 were male.
The detailed results are shown in Table 3. Blue dye was
found at the glenohumeral joint spaces in all 12 shoul-
ders (Fig. 3). The accuracy of glenohumeral injection
using superior approach with internally rotated shoulder
was 100% (12 of 12 shoulders). However, blue dye was
found at the subacromial-subdeltoid bursa in 2 of the 12
shoulders. The clinician’s confidence scores were high in
92% (11 of 12 shoulders). In all cases, the needle passed
lateral side to the long head tendon of the biceps brachii
and did not penetrate that tendon.
DISCUSSION
When an indirect ultrasound-guided technique was
used, the accuracy of injection increased to 100% and
injury to the long head of bicep brachii tendon did not
occur (0%). There are 4 important differences between
previous studies that used the superior approach and this
study [1]. First, the ultrasound was used for identifying
the location of the long head of biceps brachii tendon be-
fore needle insertion in this study. Ultrasonography was
used so that the safety of this area could be confirmed
in a clinical setting. Second, the shoulder position of ca-
daver was changed. The shoulder had been positioned at
10° internal rotation with no adduction in previous study.
In this study, the position was 10° adduction and 60°—70°
internal rotation, so that the angle of the axial rotation
could increase internally. Third, the needle entry point
was moved from anterior aspect of acromioclavicular
joint in a previous study to 5 mm laterally in the current
study. Finally, the needle advancement in a previous
study, which had been a 10° lateral and a 10° dorsal direc-
tion, was changed to 20° lateral and 20° dorsal direction.
The needle was more dorsolaterally tilted to access the
top of the glenohumeral joint capsule.
Despite the high accuracy of the superior approach,
needle injury to long head of the biceps brachii tendon
occurred in 15.8% in previous cadaver studies [1,2]. The
greater the shoulder is internally rotated, the more the
long head tendon of biceps brachii moves toward the me-
dial side [3]. The synergic effect of more laterally located
needle from 10° to 20° and to medially locate the long
head tendon of biceps brachii was expected to prevent
injury of that tendon from the needle. As we expected, no
damage to long head tendon of biceps brachii occurred
in this study (0%).
Recently, it has been reported that the direct ultra-
sound-guided method increased the accuracy of gleno-
humeral joint injection. A relatively high accuracy was
achieved by that method. Rutten et al. [4] reported a 96%
success rate with anterior approach and 92% with poste-
rior approach. Needle tip and target could be visualized
in a real time with direct ultrasound-guided injection
technique. However, this technique may increase chance
of infection because ultrasound transducer or gel could
be a medium for the microorganism contamination, such
as staphylococcal infection [5]. Thus, it requires aseptic
gel and sterile envelopes for the probe in order to mini-
mize the risk of infection. It cost more money than the
indirect method to use these instruments. The clinician
who performs this technique should coordinate between
the needle insertion and handling of the probe. It is
somewhat more difficult for the non-experienced person
to perform. In addition, the needle should advance in-
line and parallel to the ultrasound transducer to improve
visualization of the needle tip in the direct technique.
This increases the distance from the needle entry point at
skin to the target. The shorter distance could be achieved
in the indirect technique than the direct technique. If a
high accuracy around 100% could be achieved by the in-
direct technique resolving these disadvantages of direct
technique, indirect technique seems more useful in clini-
cal settings.
In addition to these advantages with indirect ultra-
sound-guided technique, we used a superior approach
method. The superior approach has many advantages [6].
This approach has the relatively shorter distance from
skin to glenohumeral joint space than anterior or poste-
rior approaches. It is easy to palpate acromioclavicular
joint, which is used for landmark of needle entry point.
Finally, in this approach, there is no major nerve or ves-
sels on the course of needle compared with anterior or
posterior approaches. The anterior approach could dam-
age the cephalic vein, axillary artery, and the brachial
plexus. Posterior approach would damage the supracla-
vicular nerve and circumflex scapular vessels [7,8].
The supraspinatus muscle is penetrated during the su-

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perior approach. However, it is expected that there are
no significant harms. The penetrated muscle location is
far from the supraspinatus tendon, so risk of the tendon
injury is very low. Injury to the supraspinatus muscle is
limited because the muscle is frequently penetrated dur-
ing arthroscopy via superior portal and the needle used
in shoulder injection and has much a smaller diameter
than the scope used in arthroscopy [9].
Considering glenohumeral joint has been mostly in-
jected to patients with adhesive capsulitis, the internally
rotated shoulder position during procedure would be
expected to be easier to perform. Because most of the pa-
tients with adhesive capsulitis show limitation of active
and passive range of motion mainly affects external rota-
tion and abduction than internal rotation [10].
Blue dye was found at subacromial-subdeltoid bursa
space in 16.7% (2 of 12 shoulders). In those 2 cadavers,
blue dye was also found at the glenohumeral joint space
at the same time. This is explained by possibility of full
thickness rotator cuff tear. The prevalence of rotator
cuff tears in asymptomatic patient was increased with
age of patients. Tempelhof et al. [11] reported that the
prevalence of rotator cuff was 31% in patient aged 70 to
79 years and 51% in aged over 81 years. The ages of the
2 cadavers at which shoulders blue dye was found were
77 and 93 years. Generally glenohumeral joint space and
subacromial-subdeltoid bursa space are separated, but
in a rotator cuff tear, those spaces are connected to each
other [8]. Therefore, blue dye could be seen at subacro-
mial-subdeltoid bursa space in those cases despite of
correct injection.
Although sitting position is preferred to supine during
in outpatient clinical settings, it is difficult to simulate
shoulder injection with cadaver with sitting position.
In cadaver, subluxation of the shoulder joint occurred
in this position because no dynamic forces exist against
gravity. The cadavers with supine position have been in-
volved as the subject to resolve these problems.
There are some limitations in this study. The clinician
who performed injections in this study has had wide ex-
perience with the superior approach. The success rate of
the superior approach could be different from the rate
in this study depending on the experience of the clini-
cian. The needle tip touched the articular surface of the
humerus once, during whole procedure, it can damage
the articular cartilage. However, it hasn’t been reported
yet whether touching of the needle tip to humeral head
during injection procedure would cause damage to the
cartilage. Furthermore, it would occur even if the direct
ultrasound-guided technique or the fluoroscopic guided
technique is done.
In conclusion, the combination of indirect ultrasound-
guided technique and positioning the shoulder internally
rotated at 60°—70° during the superior approach of gle-
nohumeral joint injection would be very effective way to
avoid damage to the long head tendon of the biceps bra-
chii and to produce a highly accurate injection.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article
was reported.
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