Sports Medicine: Just the Facts

7. Delivering the steroid: When in a joint the bolus
   technique can be used; there should be a free flow
   with no resistance. When injecting near a liga-
   ment or tendon some authors recommend a pep-
   pering technique. When injecting in a tendon
   sheath, the ideal injection demonstrates a free low
   of fluid that fills the sheath. Prior to injection, the
   patient can be asked to move the affected tendon;
   if the needle moves this suggests that the clinician
   is in the tendon and the needle should be backed
   up.

• Postprocedure care:Any afterpain can be relieved
  with ice or taking a short course of a nonsteroidal anti-
  inflammatory medication. The patient should be
  informed that the anti-inflammatory effect of the cor-
  ticosteroid may not kick-in for 48 to 72 h, and that the
  anesthetic will quickly wear-off (see Fig. 71-1). It is
  recommended that strenuous activity be avoided for a
  period of 10 days to 2 weeks following an injection.
  Rehabilitative exercise, however, may be commenced
  within 2 to 3 days.


• Evidence-based medicine evaluation of steroid
  injections:There is currently insufficient quality data
  to provide a definitive answer on the efficacy of
  steroid injections. New investigations that are
  methodologically sound are needed to measure out-
  comes of steroid injections (McNabb, 2000).

SPECIFIC INJECTIONS (Pfenninger, 1994;
Klippel and Dieppe, 1997; Anderson, 1994;
Saunders and Cameron, 1997; Safran, 1998)

• Subacromial space
  
  
  1. Indications: For the relief of pain in subacromial
     impingement syndrome
  
  
  2. Clinical anatomy/Landmarks: Useful landmarks
     include the acromioclavicular(AC) joint, the pos-
     terior glenohumeral joint, and the posterolateral
     corner of the acromion.
     3. Technique: This injection is most easily accom-
     plished with the patient in a seated position. The
     arm should be in a relaxed position, dependent
     position; the other arm may be used to provide
     traction on the shoulder to be injected. The poste-
     rior edge of the acromion is palpated, with a recess
     identified inferior to this edge providing the portal
     for the injection. The needle is inserted bevel-up in
     a slightly cephalad angulation, pointed to the AC
     joint. If bony resistance is felt the needle is most
     probably in the acromion, and the needle should be
     redirected inferiorly. Insertion depth is approxi-
     mately 1 in.
     4. Needle size and dosage: One milliliter of corticos-
     teroid in combination with 6 to 10 mL of long and
     short acting anesthetics. A 22-gauge long 1^1 / 2 -in.
     needle is recommended when injecting a large
     volume.
  
  
  
  


• Glenohumeral joint

1. Indications: Inflammatory or degenerative arthri-
   tis, adhesive capsulitis


2. Clinical anatomy/Landmarks: Coracoid process,
   humeral head, and the acromial process of the
   scapula


3. Technique: The seated position is most comfortable
   for this injection. The coracoid process is identified
   inferomedial to the AC joint, with the anterior
   glenohumeral joint is inferior to the coracoid and
   appreciated by internally and externally rotating the
   shoulder. At the same time the posterior gleno-
   humeral joint can be appreciated. The technique is
   the same as the subacromial injection; however, the
   needle is now aimed to the coracoid process. The
   depth of penetration is approximately 1 in.


4. Needle size and dosage: A 25-gauge 1^1 / 2 -inch
   needle is recommended; one mL of corticosteroid
   can be combined with 5 to 10 mL of anesthetic.

• Acromioclavicular joint

1. Indications: Acromioclavicular degenerative dis-
   ease
   2.Clinical anatomy/Landmarks: Important land-
   marks are the clavicle and acromion. The AC joint
   can be conveniently located by abducting the
   shoulder.


2. Technique: The injection is conveniently adminis-
   tered by having the patient in a seated position. The
   injection is most easily accomplished by coming
   from above with the needle directed inferiorly. An
   insertion depth of^3 / 8 to^1 / 2 in. is required. A prein-
   jection radiograph of the angle of the AC joint can
   be useful.


3. Needle size and dosage:^1 / 2 - to 1-in. 25-gauge
   needle is appropriate; 0.5 mL each of anesthetic and
   corticosteroid is adequate.

430 SECTION 5 • PRINCIPLES OF REHABILITATION

FIG. 71-1 Pain relief and injection therapy.