Shoulder
The shoulder is an excellent region for the use of ultrasound-guided diagnosis and intervention due to its high injury prevalence and the superficial nature of commonly injured structures (Peng P, Cheng P, Reg Anesth Pain Med 36:592–605, 2011). The should
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Shoulder Naimish Baxi and David A. Spinner
The shoulder is an excellent region for the use of ultrasoundguided diagnosis and intervention due to its high injury prevalence and the superficial nature of commonly injured structures [1]. The shoulder girdle, composed of the scapula, clavicle, and proximal humerus, gives rise to the glenohumeral (GH), acromioclavicular (AC), and sternoclavicular joints. The deltoid, long head of the biceps brachii, and rotator cuff muscles (the supraspinatus, infraspinatus, teres minor, and subscapularis) facilitate shoulder movement in almost every plane [2]. The biceps tendon sheath, AC and GH joints, and subacromial/subdeltoid bursa (SASDB) are common sites for injection. There are also newer promising interventions, including prolotherapy, percutaneous needle tenotomy, and platelet-rich plasma, targeting rotator cuff tendons with ultrasound guidance.
Long Head of Biceps Brachii Tendon Sheath Inflammation of the biceps tendon or sheath (tenosynovitis) from isolated injury or overuse is a common source of shoulder pain [3]. As the tendon passes through the bicipital groove of the humerus toward its insertion onto the superior labrum, it is exposed over the anterior region of the shoulder. The long head of the biceps contributes to humeral head stability, especially during abduction and external rotation [4]. Presenting symptoms may include anterior shoulder pain and discomfort. Injections to the biceps tendon sheath are historically performed blind.
N. Baxi, MD OSS Health, York, PA, USA e-mail: [email protected] D.A. Spinner, DO, RMSK (*) Department of Anesthesiology – Pain Medicine, Arnold Pain Management Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline, MA, USA e-mail: [email protected]
A recent study by Hashiuchi et al. (Table 2.1) demonstrated that 86.7 % of ultrasound-guided injections achieved contrast within the tendon sheath compared to 26.7 % performed with the blind technique. Of those that were performed blind, another 33 % were completely outside the tendon sheath compared to 0 % when ultrasound was utilized [5]. Gazzillo et al. demonstrated that palpation-guided needle placement locating the long head of the biceps tendon was accurate only 5.3 % of the time without ultrasound verification [6].
Scanning Technique and Anatomy to Identify For an optimal view of the biceps tendon, the patient’s hand should be supinated with the elbow flexed, lying on the ipsilateral thigh. With the transducer placed in the axial plane over the proximal humerus, the hyperechoic tendon of the long head of the biceps brachii can be visualized within the bicipital groove. The transverse humeral ligament lies superficial to the tendon. The subscapularis tendon can be seen medially. Using Doppler imaging, the ascending branch of the circumflex humeral artery may be visualized laterally. Turn the transducer 90° to view the tendon longitudinally. Sweep medially to view the pyramid shape of the lesser tuberosity (Fig. 2.1) [7].
Injection Techniques: In-Plane A
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