Shoulder (subacromial space) Injection

Table of Contents

Table of Contents

Published February 2021; reviewed Jnauary 2023

Brandon Fainstad, MD1, Molly Brett, MD1, Lisa Thompson, MD1, Meara Melton, MD2

1 Assistant Professor, Department of Medicine, University of Colorado, 2 Fellow in Geriatric Medicine, University of Colorado

Objectives

  1. Determine appropriate indications and contraindications for a steroid injection of the subacromial space.  
  2. Perform all critical steps of a subacromial steroid injection (except needle insertion) using a high-fidelity simulation-based training under direct preceptor observation. 
  3. Perform all critical steps of a subacromial steroid injection in a clinical environment under direct preceptor observation.

Teaching Instructions

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.

Pre-work

The day before you plan to do an in-person procedure training ask your trainees to review:

Pre-quiz WITHOUT answers


Pre-Quiz WITH answers


Clinical Video

  1. Watch this 3-minute video of the clinical procedure for trainees. (https://vimeo.com/520388383)

Simulation Training

Instructor Video

Simulation Checklist

Clinical Procedure

Instructional Video

Play Video

Clinical Checklist

Supply list

Lidocaine 1% (5cc)
Triamcinolone 40mg/ml (1cc)
Alcohol swabs (#2)
5-10cc syringe
18g needle (for drawing up)
21-25g 1.5” needle (for injection)
Marker
Chlorhexidine swab
2×2 gauze
Band-aid

Example procedure note

Indication (subacromial bursitis, rotator cuff tendinosis, rotator cuff impingement, or adhesive capsulitis): 
Procedure: Shoulder (subacromial space) injection
Performing provider: _ 
Supervising Physician (if applicable): _
Consent: obtained and saved in the chart
Time-out confirming correct procedure, location, and patient (2 identifiers): performed 
 
Procedure: The spine of the scapula and lateral margin of the acromion was marked for anatomic landmarks.  The insertion point was marked 2cm below the posterior-lateral point of the acromion.   The area was prepped in the usual sterile manner. Then a 21g needle was inserted into the marked insertion point then advanced to a depth of 3cm.  Attempt for aspiration was performed without bloody return.  Then a combination of ____cc's of 1% lidocaine and 1cc of 40mg/cc of triamcinolone was injected without resistance or patient discomfort.  The needle was then removed and a bandaid applied over the insertion site. 
 
Follow-up: The patient tolerated the procedure well without complications.  Standard post-procedure care and return precautions were provided. A consult for physical therapy was also placed and the patient was strongly encouraged to start their physical therapy within the next 4 weeks to improve the long-term benefits of the procedure. 

References

McNabb, J. W. (2014). A Practical Guide to Joint & Soft Tissue Injections. United States: Wolters Kluwer Health.

AAOS. (2018). Essentials of Musculoskeletal Care. United States: Jones & Bartlett Learning, LLC.

Tallia, A. F., & Cardone, D. A. (2003). Diagnostic and therapeutic injection of the shoulder region. American family physician67(6), 1271-1278.

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