Shoulder (subacromial space) Injection

Have the learners watch a brief introductory video (below), review the clinical checklist, and take the pre-quiz below to assess their own knowledge the day prior to procedure training.

Consider combining simulation with a review of the shoulder exam (a brief demo as well as practice cases – see below) for a total of ~70 minutes.  

Shoulder exam training: 

We begin by having the instructor demonstrate a brief ~2 minute shoulder exam on a volunteer learner. Throughout the demonstration, we explain the clinical context for each exam maneuver (e.g. what hypothesis are we looking to prove/disprove with each maneuver?) and share the accuracy (e.g. likelihood ratio) of various parts of the exam.

Then, trainees break into small groups. They work through cases with one participant serving as clinician and the other as model.  Each case provides a background history; as the “clinician” trainee examines his or her peer, the pertinent physical findings are shared. Finally, the “clinician” is asked for the diagnosis and next steps in management.   

Procedure training:

It is critical that both the learner and instructor treat the simulation like a true clinical encounter.  This provides more opportunity for the instructor to identify and correct learner errors, and to reduce the intrinsic and extrinsic cognitive load for the learner when they perform the procedure in a clinical setting.  Have each learner take turns being the proceduralists with another willing-learner or standardized patient serving as the model.  Move through the procedural worksheet, step-by-step.  Do not omit the critical step of clearly identifying appropriate indications and contraindications.  For the simulation, we simply ask the learner to list the potential indications and contraindications.  In the clinical procedure, we ask for the specific indication identified for this encounter and ask the learner to report the historical feature and/or demonstrate the physical exam finding that supports the proposed diagnosis.

We use a “no-touch technique” for this procedure. Using non-sterile gloves learners identify the supplies all necessary supplies for the procedure.  We ask them to draw up the lidocaine and steroid from pre-filled vials of saline while offering suggestions for improved technique.  These tips include cleaning the vial tops with alcohol swabs, using a separate needle for drawing up solutions and for the procedure, injecting air into a vial when drawing up more than 3cc's, and drawing up lidocaine first so a small amount can be injected into the small steroid vial to increase the amount of steroid than can be aspirated.

After the supplies are prepped, we supervise the correct identification and marking of the scapular spine and lateral margin of the acromion.  Learners will draw two straight and connecting lines to identify the posterior-lateral point of the acromion.  Then identify the insertion roughly 1-2cm below that point in a recess with minimally palpable muscle or tendons.  After the site is correctly marked, the learner will sterilize the site using the scrub technique (30 seconds).  Then, while using their non-dominant hand to stabilize and support the patient's shoulder, they will use the capped injection needle to demonstrate their preferred approach to the injection site.  Their approach should angled under the acromion and slightly cephalad toward the coracoid process. After providing feedback on the trajectory, the learner verbalizes the remaining steps of the procedure.

Ideally, the simulation training closely precedes (hours to days) the clinical procedure, allowing for maximal opportunity to reinforce the learning in a clinical setting.  However, this is often not possible.  Either way, the learner should watch the clinical procedure video beforehand and verbally review the steps of the clinical checklist before starting the procedure.  Again, one of the most important and often overlooked steps is the learner's correct identification and demonstration of an appropriate indication.  It is important to educate the patient on the value of physical therapy in providing more long-term, sustainable benefits to the procedure.