AMERICAN JOURNAL OF PHYSICAL MEDICINE

&REHABILITATION :
JANUARY 2006-VOLUME 85-ISSUE 1-PP31-35
RESEARCH ARTICLE: INJECTIONS

U LT R A S O U N D - G U I D E D
SHOULDER INJECTIONS IN
T H E T R E AT M E N T O F
SUBACROMIAL BURSITIS
C H E N , M A X J . L > M D ; L E W , H E N RY L . . M D , P H D ;
HSU, TSZ-CHING MD,PHD;TSAI, WENC H U N G M D , P H D ; L I N , W E I - C H I N G M D ; TA N G ,
S I M O N F. T M D ; L E E , Y A - C H E N M D ; H S U , R E X
C . H . M D ; C H E N , C A R L P. C . M D

BACKGROUND
Subacromial bursitis is
The inflamed subacromial bursa
The clinical picture is charaterized by
- anterior shoulder pain
- restriction of the range of motion of the
shoulder
Develops in athletes who throw

THE OBJECTIVE
To investigate the treatment effectiveness
between ultrasound-guided and blind
injection technique in the treatment of
subacromial bursitis

ANATOMY OF THE SUBACROMIAL BURSA

 The diagnosis of subacromial bursitis :

1. Direct palpation over the subacromial
bursa
2. Subacromial arthrography and magnetic
resonance imaging (MRI)
3. Ultrasound

 The treatment is:

- Rest, icing, anti-inflammatory medications
- In refractory patients---local injection of a
steroid into the bursa maybe necessary
In this study :
To investigate the treatment effectiveness
between ultrasound-guided and blind
injection techniques in the treatment of
subacromial bursitis

METHODE
A total of 40 patients with sonographic
confirmation of subacromial bursitis
The age from 30 - 66 yrs (average 53 yrs)
The duration was 2-10 mo
The ratio of men women was 2:1
Px divided into 2 group : 20 px in each
group

The inclusion criteria were:

- History of shoulder pain > 1 mo
- Shoulder pain that could be elicited
during
abduction maneuvers
- Shoulder ROM limitation & the existence
of a painful are synd.
The excluded criteria were :
Px with capsular lesions of the shoulder

All subjects signed informed consent

The LOGIQ 9 (General Electronic Company,
Milwaukee, WI) was the ultrasound machine
used for ultrasonographic examinations.
The 10 L probe, 4-10 MHz (General
Electronic Company, Milwaukee, WI) was
used to assess the shoulder.

Patients position :
All px sat in an upright position and with the
back well supported
The arms were positioned behind their backs
and with the elbow bend

Ultrasonographic position ;
The sonogram coracoacromial window
was obtained by placing the probe on
the counter of the shoulder lateral and
parallel to axis of the underlying
supraspinatus tendon

SUPRASPINATU
S.
THE PATIENT IS
THEN ASKED TO PLACE
THEIR HAND ON THEIR
HIP WITH THE
SHOULDER ADDUCTED
AND INTERNALLY
ROTATED AS MUCH AS
IS COMFORTABLE FOR
THE PATIENT (SIMILAR
TO PUTTING YOUR
HAND IN YOUR

POCKET
POSITION).

BACK

The humeral head, supraspinatus, deltoid

were clearly observed under the
coracoacromial window

FIGURE 2
Ultrasound-Guided Shoulder Injections
in the Treatment of Subacromial Burs
itis

Chen, Max J. L.; Lew, Henry L.; Hsu,

Tsz-Ching; Tsai, Wen-Chung; Lin, WeiChing; Tang, Simon F. T.; Lee, YaChen; Hsu, Rex C. H.; Chen, Carl P. C.
American Journal of Physical
Medicine & Rehabilitation. 85(1):3135, January 2006.
doi:

FIGURE 2The sonogram

coracoacromial window. The
humeral head, supraspinatus,
and deltoid were clearly
observed under the
coracoacromial window.

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R E H A B I L I TAT I O N . P U B L I S H E D BY L I P P I N C O T T W I L L I A M S & W I L K I N S .

17

The subacromial bursitis was observed

under the sonogram as a region of
hypoechoic effusion between the
deltoid and the humeral head.

FIGURE 3
Ultrasound-Guided Shoulder Injections
in the Treatment of Subacromial Burs
itis

Chen, Max J. L.; Lew, Henry L.; Hsu,

Tsz-Ching; Tsai, Wen-Chung; Lin, WeiChing; Tang, Simon F. T.; Lee, YaChen; Hsu, Rex C. H.; Chen, Carl P. C.
American Journal of Physical
Medicine & Rehabilitation. 85(1):3135, January 2006.
doi:

FIGURE 3The hypoechoic

region depicting the
subacromial bursitis (arrow).

COPYRIGHT 2010 AMERICAN JOURNAL OF PHYSICAL MEDICINE &

R E H A B I L I TAT I O N . P U B L I S H E D BY L I P P I N C O T T W I L L I A M S & W I L K I N S .

19

THE BLIND INJECTION TECHNIQUE

palpation of the acromial by thumb, and
then the needle wa was inserted in a
horizontal approach.
The needle was first adjusted in different
depths and angle in trying to aspirate the
effusion
If no effusion could be aspirated, injected
the steroid lidocaine suspension into the
subacromial bursa

THE ULTRASOUND-GUIDED
INJECTION TECHNIQUE
The needle was inserted into the subacromial
bursa under ultrasound guidance.
Aspiration of the effusion was done first
before injecting steroid-lidocaine
suspension into the subacromial bursa
Under sonogram, the needle was observed as
a hyperechoic structure.

FIGURE 4
Ultrasound-Guided Shoulder Injections
in the Treatment of Subacromial Burs
itis

Chen, Max J. L.; Lew, Henry L.; Hsu,

Tsz-Ching; Tsai, Wen-Chung; Lin, WeiChing; Tang, Simon F. T.; Lee, YaChen; Hsu, Rex C. H.; Chen, Carl P. C.
American Journal of Physical
Medicine & Rehabilitation. 85(1):3135, January 2006.
doi:

FIGURE 4Ultrasound-guided
injection treatment of
subacromial bursitis.

COPYRIGHT 2010 AMERICAN JOURNAL OF PHYSICAL MEDICINE &

R E H A B I L I TAT I O N . P U B L I S H E D BY L I P P I N C O T T W I L L I A M S & W I L K I N S .

23

RESULTS
BLIND INJECTION
GROUP

U LT R A S O U N D GUIDED
INJECTON
GROUP

ROM Abduction
shoulder before
injection 12.38

ROM Abduction shoulder

before injection
14.72

ROM Abduction
shoulder 1 wk after
injection 18.8

ROM Abduction shoulder

1 wk after injection
20.4

No statistical difference

Significant difference

(P > 0.05)

(P< 0.05)

The paired Students t test was used to determine

whether there was a significant difference in
shoulder abduction range of motion before and 1 wk
after the injection in both groups.
Significant difference was defined as P < 0.05

DISCUSSION
Subacromial bursitis is often secondary to
lesions in the tendinous cuff and a common
cause of anterior shoulder pain and
frequently develops in athletes who throw.
Soft-tissue ultrasound has proven to be an
effective imaging tool in the diagnosis of
subacromial bursitis

In treatment, subacromial bursitis ordinarily

responds well to ice, rest, physical modality,
and anti-inflammatory medications
In refractory cases, local injection of steroid
suspension into the subacromial bursa may
be needed

In clinical setting, most injections are

performed via the blind palpation
technique.
However, even an experienced physician
performing the blind injection technique can
never certain if the steroid-lidocaine
suspension is injected accurately into the
inflamed bursa

In this study, ultrasound an effective

imaging tool in performing ultrasoundguided shoulder subacromial bursitis
injections & aspirations.
The significant improvement in shoulder
abduction ROM after ultrasound-guided
injection was accurately infiltrated into the
lesion site as compare with the blind
injection technique

CONCLUSION
Based on the result obtained in this study,
ultrasound may be used as an adjuvant tool
in guiding the needle accurately into the
subacromial bursa to perform effective
injection treatment
The ultrasound-guided injection technique in
the treatment of subacromial bursitis can
result in significant improvement in
shoulder abduction ROM as compared with
the blind injection technique

TERIMA KASIH

Bearing in mind that the supraspinatus

runs in a plane at 30 to the coronal
plane of the body the probe should be
placed for a longitudinal view of the
suprsapinatus between 30 and 60 to
the coronal axis of the plane of the
body. This should give a good view of
the greater tuberosity footprint area
and superior articular surface of the
humeral head. The probe can then be
moved from antero-medial to posterolateral, i.e. from the anterior leading
edge of supraspinatus towards the

The probe is then rotated 90 for a transverse view of the

supraspinatus and anterior portion of the infraspinatus
tendons (superior cuff). The probe can then be moved
medially and laterally as well as antero-medial and posterolateral for a good impression of this area. Further medial
movement is limited by the acromium.