 Hi, my name is Dr. Ankit Shah. I'm a practicing radiologist at Willepale West at Eklat polyclinic. My special area of interest is muscular skeletal imaging and today I will be talking on ultrasound guided injections around the shoulder joint. Thank you for joining in. Let's begin with something very basic which probes to begin with. We always start with linear probes especially when we want to inject the bicep standard sheath or the acromioclavicular joint or even the subacromyl subdeltoid bursa. Our standard workhorse is the linear probes. Now you really don't need a very high resolution linear probe. Even your standard 11 to 9 megahertz probe is good enough. And if you have a hockey stick probe that you can use for injection of the acromioclavicular joint. There are two basic techniques for needle visualization. One is a long axis technique or the in plane technique where your needle is parallel to the probe. So your needle will be visualized as an echogenic linear structure all along its length or what you have is a short axis technique where your needle is perpendicular to the ultrasound beam wherein your needle will be only seen as a bright dot. This is how the needle looks in the long axis. You can see the entire needle all along its course and this is the needle tip. So most of the people while doing ultrasound guided interventions they would like to use a long axis technique. However sometimes if the structure is deep or if the plane is not very suitable for putting the probe in an appropriate manner you might also have to use a short axis technique where all you will be able to see is just a part of the needle or sometimes you might have to do a combination of both. Now one more thing you need to remember is that keep the needle as parallel to the probe as possible because if the angulation of the needle is more than 45 degrees the visualization of the needle becomes more and more difficult. Now if we see in this video over here as the needle becomes more and more parallel with the probe you see the needle is visualized even better. So let's start with the subacromial injections. So if you are a beginner and if you have to start with musculoskeletal ultrasound guided interventions this is the most simplest injection you can begin with. So there are two techniques or there are two positions that you can use. One is via the anterior approach wherein the patient is lying supine and you go from lateral to medial or you use the lateral to medial approach where you make the patient lie down straight and or you make the patient sit straight and you approach from lateral to medial. So this is how it works. This is a probe position on the anterior aspect where you put your probe along the anterior aspect of the shoulder and you put your needle and as it goes from medial to lateral you go between the deltoid and the rotator cuff the space is a subacromial subdeltoid borsa. Again this is the video over here the graphic showing the position of the needle going from lateral to medial aspect entering within the subacromial subdeltoid borsa. Now as a beginner you need to count the levels of tissues from the skin surface to the bone to identify the rotator cuff which we have already covered in one of the previous lectures. So right from the beginning you have the subcutaneous fat over here followed by the deltoid muscle belly between the deltoid and the rotator cuff this echogenic layer that's your subacromial subdeltoid borsa or the peri borsa fat. So whenever you have to inject within the subacromial subdeltoid borsa this is the plane you will be targeting. So your needle comes from lateral it traverses the subcutaneous fat the deltoid and it deposits the drug within the subacromial subdeltoid borsa. Over here what I have shown is the position of the probe and the position of the needle how it will be approaching the subacromial subdeltoid borsa. So let's take one case over here with a 57 year old male with frozen shoulder what we see is the needle has come from lateral to medial as it goes over here this linear structure that's the needle and it enters the subacromial subdeltoid borsa and as you inject the steroid you see that there's nice distinction of the borsa that we see over here. Another patient this was a 73 year old male with secondary frozen shoulder so what we see is that the needle is seen in a long axis and as the needle comes over here and as you inject within the subacromial subdeltoid borsa on this clip you see that as in when you inject you see the anechoic fluid distending the subacromial subdeltoid borsa. Now these are the kind of cases that you would really like to begin with so this was a 63 year old female with subacromial subdeltoid bursitis she had an underlying inflammatory arthropathy so the MRI shows a nicely distended subacromial subdeltoid borsa this hyper intense structure that we see that's the fluid within the borsa and on the coronal you see the borsa going beyond the greater tuberosity so you see the needle coming through the deltoid you enter the subacromial subdeltoid borsa and once you inject the fluid you see the injected being inserted within the subacromial subdeltoid and this is how this the procedure was done the patient was made to lie down with the unaffected side down and this is how the position of my needle and the probe so this was one 44 year old male with calcific tendinosis was referred for injection within the subacromial subdeltoid borsa what we see is this is a calcium within the tendon over here and this is the needle which comes and as we inject within the subacromial subdeltoid borsa there's distension of the subacromial subdeltoid borsa that we see over here so these are some common examples of injection within the subacromial subdeltoid borsa after this we come to glenohumeral joint injections so one of the most common indications for glenohumeral joint injection is adhesive capsulitis or frozen shoulder so before that it's a great idea to have a small recap of what the anatomy of the glenohumeral joint looks like on ultrasound so what we see over here is if we place our probe along the posterior aspect of the shoulder on the short axis so we see the infraspinatus below the infraspinatus you see the glenoid and the humerus and that's the glenoid labrum that we see so if your needle has to come it goes from lateral to medial aspect and it enters the joint in this manner and you once you're inside the joint you deposit the steroid or the whatever injected which you have prepared within the joint cavity so let's take this one fifth case which is a 54 year old female with frozen shoulder so this is the needle which goes through the infraspinatus so this is the glenohumeral joint cavity and this is the needle which has entered the joint and what I'm doing is as I inject you see that this distension of the joint capsule so once again that's the needle entering the joint through the infraspinatus muscle belly once it enters the joint over here as it enters and once the needle is over here I inject and you see distension of the joint capsule over here what you see is this is how you position the patient you make the patient lie prone and you go from lateral to medial aspect so this is another 74 71 year old female with frozen shoulder the pre procedure radiograph looks uh undermarkable except for a little bit of acromia clavicular joint arthritis so this is what the uh we position the patient prone with the arm uh abducted and as you go from lateral lateral to medial this is the position of the needle as it enters the joint over here and then once the needle is seen within the joint you gradually inject your injectate and you will see that this distension of the joint or you see uh small bubbles as you inject within the joint cavity so with this we move on to acromia clavicular joint injections there are at least two ways that you would want to approach the acromia clavicular joint one is visualize the needle on the long axis either going from lateral to medial or what I prefer to do is visualize the needle in the long axis from anterior to posterior so these are the two commonly used techniques where you wherein you visualize the needle on the long axis or you can also visualize the needle on the short axis in this fashion wherein you connect the acromia clavicular joint uh the acromion and clavicular uh tool and you identify the joint in the short axis and you go from posterior to anterior so let's see how it goes so this is ultrasound anatomy of the acromia clavicular joint so this is the acromion and that's the clavicle and this is a superior acromia clavicular ligament and as you go from uh from lateral to medial this is how the needle looks it penetrates the joint and this is how you deposit the injectate over here how we do it from anterior to posterior how does it work so if you look at the anatomy you know there have been lots of new papers wherein they say that there's a natural opening of the acromia clavicular joint anteriorly so if you see on the CT this these are the actual views wherein you see that the acromia clavicular joint opens up anteriorly and this is a 3D view so if you have to enter the joint there's a natural opening so this is what I prefer I prefer to go from anterior to uh posterior because that makes my life much more easier this was one case with a 36 year old male volleyball player with shoulder pain and the patient had acromia clavicular joint osteoarthritis so as I go from lateral to medial this is I this is my needle tip within the joint and as once my needle tip is within the joint I inject over here and you see that injected flowing within the joint now mind you this acromia clavicular joint is a very small or a tightly packed joint so even if you get in around 1 ml of fluid that's quite a bit or maybe 1.5 but definitely not more than that this is uh how you inject within the acromia clavicular joint using a long axis technique from lateral to medial this was a patient with acromia clavicular joint osteoarthritis so what we see is that there is edema along the lateral aspect of the clavicle there are some osteophytes as well so this is what I prefer going from anterior to posterior so this is the anterior aspect of the joint this is my needling a needle entering the joint and once I inject over here I see that there's distension of the joint capsule quite simple if you're a beginner I think acromia clavicular joints can be very easy joints to start with this was a young weight lifter so after lifting weights he was having a lot of pain you know so he was diagnosed with distal clavicular osteolysis and he was advised for an acromia clavicular joint injection so this is what it looks like you enter the joint from anterior to posterior this is the needle entering and once the needle enters you inject and you see the injectate flowing within the joint all right so anterior to posterior your needle enters and this is how the injectate looks as it enters the joint now needling of calcific tendinosis is something that nowadays we get asked more often what you do is you scan the patient first and identify the calcific deposit because that's where you'll be inserting your needle it is done in two or rather three basic steps step one is wherein you inject local anesthesia or two percent lignocaine in the subacromial subdeltoid bursa and the overlying skin anesthetize that area following which what you do is you insert your needle and you try and break the calcium you try and break the calcium all right you do multiple attempts with that you push in a little bit of saline and lignocaine and you try and break the calcium and whatever comes out that's going to be here the calcium which gets dissolved it comes out through the same syringe this is either you call it a needling of the calcium or this is also known as calcium barbotage so these are the basic steps all right so this was one 56 year old female with calcific tendinosis what we see is that there's soft calcium within the rotator cuff tendon this is the ap and the axillary views we see the calcium pretty well and this is how it goes we go within the calcium you inject saline within it and you kind of try and break it up and you try and aspirate the calcium and once you've done that done that procedure you inject a steroid within the subacromial subdeltoid bursa so this was what we aspirated from the calcium now we feel that you know that calcium must be a thick chalky material but it actually turns out to be a paste like material that this is what you can aspirate so this was another case with a 44 year old male with calcific tendinosis this is a radiograph showing soft calcium this is what we see on the ultrasound this is a cuff and that's a soft calcium over here so this is what we do we first we inject within the subacromial subdeltoid bursa once this once a patient is anesthetized what we do is we put in the needle within the calcium we inject a little bit of most saline and a little bit of lignocaine and what we do is we try and fragment the calcium and once you do that this fragmented calcium can be aspirated by the same needle take home points is ultrasound results in better accuracy especially when which area you want to inject you want to inject within the subacromial subdeltoid bursa the glenohumeral joint the acromial clavicular joint because these are very small and these are very thin structures so where you're injecting that is of at most importance so that you get them the patient gets the maximum benefit of that injected drug and the whole point of using ultrasound guidance for subacromial subdeltoid bursal injections or the glenohumeral joint is we want to avoid damage to the rotator cuff tendon we really do not want to inject within the tendon because if you inject a steroid within the tendon it's going to result in tendon weakening and ultimately it results in a tendon tear and of course once you use ultrasound before doing any kind of procedure it helps you in better in better decision making and prognosticating the disease the disease process and communicating with the patient thank you so much