Injection Locations for Adhesive Capsulitis

By: Gregory Rubin, DO

Adhesive capsulitis is seen in 2.4 out of every 1000 patients and is most commonly seen in our patients over age 50 (Rui Chen, 2019). Patients are typically complaining of the worst shoulder pain that they have ever experienced. As a result, many patients want an injection during their visit. There are three injections that are most frequently done for adhesive capsulitis. There is no clear consensus as to which injection to perform. Patients can receive injections within their rotator interval, glenohumeral joint, or subacromial bursa. The purpose of this review is to look in to the role of injection for adhesive capsulitis and to see which location is preferred.

Rotator interval

The rotator interval is the area between the anterior border of the supraspinatus and most superior portion of subscapularis (Jiro Ozaki, 1989). The interval is also thought to include the long head of the biceps, coracohumal ligament, superior glennohumeral ligament, and a portion of the joint capsule (Tore Prestgaard, 2015).

In 1989, Dr. Ozaki was evaluating patients with chronic adhesive capsulitis and found that they had a contracted rotator interval and coracohumeral ligament (Jiro Ozaki, 1989). Since that time, there has been interest in giving corticosteroid injections to both the rotator interval and coracohumeral ligament (Jiro Ozaki, 1989). In 2015 published in Pain, Dr. Prestgaard looked at pain outcomes when injecting the rotator interval and GH joint for adhesive capsulitis. The rotator interval injection was done with the patient in the supine position. Using a 13-5 MHz linear transducer, the target of the injection was the rotator interval at the level of the long head of the biceps and anterior joint capsule (Tore Prestgaard, 2015). In total, 42 patients received the intra-articular injection, 40 received a rotator interval and intra-articular injection, and 40 received a sham injection (Tore Prestgaard, 2015). They found that there was no statistically significant difference in pain scales following the intra-articular injection vs. the intra-articular and rotator interval injection (Tore Prestgaard, 2015).

A second study published in Rheumatology International also looked at the role of a rotator interval injection for adhesive capsulitis. The injection was performed by placing the patient in supine position with the shoulder externally rotated with slight abduction (Niels Gunnar Juel, 2013). The provider then found the biceps tendon within the sulcus and then rotated the probe longitudinally to the location where the biceps tendon curves over the humeral head (Niels Gunnar Juel, 2013). They then gave one injection parallel and medial to the biceps tendon into the synovium and a second angled 5-10 degrees anteriorly (Niels Gunnar Juel, 2013). The results of the study did show that statistically significant pain relief was found at 12 weeks in those patients receiving a rotator interval injection (Niels Gunnar Juel, 2013).

Glenohumeral and Subacromial injections

There have been multiple studies looking at subacromial bursa vs. GH joint injections for adhesive capsulitis. Early corticosteroid injection into the glenohumeral joint has been shown to decrease the initial synovitis (Sang-Jin Shin, 2013). In 2013 published in the American Journal of Sports Medicine, researchers looked into the optimal dose of corticosteroids to inject into the GH joint. They compared 20mg to 40mg Triamcinolone dose and found that there was no difference in pain between the two groups (Sang-Jin Shin, 2013).

Most recently published in the International Journal of Surgery, a meta-analysis was done comparing intra-articular GH injections vs. subacromial injections for frozen shoulder. They found that when reviewing five randomized control trials, the intra-articular joint injections had superior pain outcomes up to 3 months from the time of the injection (Rui Chen, 2019).

However, despite the meta analysis recommending a GH joint injection over the subacromial bursa injection, many randomized controlled trials did not show this advantage. Published in the Journal of Shoulder and Elbow Surgery in 2016, researchers looked at intra-articular GH injection vs. subacromial bursa injection vs. hydrodissection. When comparing the subgroup who received a subacromial bursa injection to GH joint injection, researchers did not find a statistically significant difference between sub-groups (Jong Pil Yoon, 2016). In 2009, Dr. Oh compared subacromial bursa to GH joint injections. What they found was that there was no statistically significant difference in pain relief from subacromial vs. GH joint injections (Joo Han Oh, 2011).

A study Published in 2013 in the Journal of Shoulder and Elbow Surgery compared patients with adhesive capsulitis and randomized them to receiving a corticosteroid injection into the subacromial bursa, glenohumeral joint, subacromial and glenohumeral joint, or oral NSAIDs (Sang-Jin Shin, 2013). What they found was that there was no difference in pain or range of motion in the groups of patients receiving corticosteroid injection. They hypothesized that the subacromial bursa patients did as well as the glenohumeral patients because of the contractures seen within the coracohumeral ligament and rotator interval in patients with adhesive capsulitis (Sang-Jin Shin, 2013).

Physicians also have to consider is whether or not the injections are given with ultrasound guidance. A study done within a department of Physical Medicine and Rehab published in 2009 looked at the role of ultrasound-guided glenohumeral joint injections vs palpation guided glenohumeral joint injections. What they found was that the group that received the ultrasound-guided injection had a statistically significant improvement in their range of motion and pain during the first 2-3 weeks (Hong-Jae Lee, 2009).

Due to the confusion over where to put the injection, Dr. Kim used a diagnostic lidocaine injection prior to a corticosteroid injection to see if patients had more pain relief within the subacromial bursa or GH joint. What they found was that those patients that received a Lidocaine injection that confirmed the location of pain as either the bursa or GH source of pain had better pain response to intra-articular GH joint corticosteroid injections (Sang Jun Kim, 2014). They hypothesized that the patient response to the injection depends on the time frame of symptom onset (Sang Jun Kim, 2014). Patients with symptoms driven from a synovitis will respond more to a GH injection, while those with contractures within the rotator interval and coracohumeral ligament will have more benefit from a rotator interval or subacromial bursa injection.

Conclusion

After reviewing the available literature, there is still no clear consensus as to where to inject patients with adhesive capsulitis because there appears to be a cohort of patients who respond to both injections. What we do know is that ultrasound-guided injections are more accurate than palpation guided intra-articular joint injections. Future research should look at physical exam maneuvers or ultrasound findings that can help providers decide which injection to pursue.

References

Hong-Jae Lee, K.-B. L. (2009). Randomized Controlled Trial for Efficacy of Intra-articular Injection for Adhesive Capsulitis. Archives of Physical Medicine and Rehabilitation, 1997-2002.

Jiro Ozaki, Y. N. (1989). Recalcitrant Chronic Adhesive Capsulitis of the Shoulder. The Journal of Bone and Joint Surgery, 1511-1515.

Jong Pil Yoon, S. W. (2016). Intra-articular injection, subacromial injection, and hydrodilatation for primary frozen shoulder: a randomized clinical trial. Journal of Shoulder and Elbow Surgery , 376-383.

Joo Han Oh, C. H. (2011). Comparison of glenohumeral and subacromial steroid injection in primary frozen shoulder: a prospective, randomized short-term comparison study. Journal of Shoulder and Elbow Surgery, 1034-1040.

Lewis, N. S. (2007). Shoulder adhesive capsulitis systematic review of randomised trials using multiople corticosteroid injections. British Journal of General Practice, 662-667.

Niels Gunnar Juel, G. O. (2013). Adhesive capsulitis: one sonographic-guided injection of 20mg triamcinolone into the rotator interval. Rheumatology International , 1547-1553.

Rui Chen, C. J. (2019). Comparison of intra-articular and subacromial corticosteroid injection in frozen shoulder: A meta-analysis of randomized controlled trials. International Journal of Surgery, 92-103.

Sang Jun Kim, A. G. (2014). Determination of steroid injection sites using lidocaine test in adhesive capsulitis: A prospective randomized clinical trial. Journal of Clinical Ultrasound.

Sang-Jin Shin, S.-Y. L. (2013). Efficacies of corticosteroid injection at different sites of the shoulder for the treatment of adhesive capsulitis. Journal of Shoulder and Elbow Surgery, 521-527.

Seung-Hyun Yoon, H. Y. (2013). Optial Dose of Intra-articular corticosteroids for Adhesive Capsulitis. The American Journal of Sports Medicine, 1133-1139.

Tore Prestgaard, M. W. (2015). Ultrasound-guided intra-articular and rotator interval corticosteroid injections in adhesive capsulitis of the shoulder: a double-blind sham-controlled randomized study. Pain, 1683-1691.