Is the Anterior Injection Approach Without Ultrasound Guidance Superior to the Posterior Approach for Adhesive Capsulitis of the Shoulder? A Sequential, Prospective Trial

Abstract

Background Shoulder injections for conditions such as adhesive capsulitis are commonly performed and can be administered through image-based or landmark-based injection approaches. Ultrasound-guided injections are widely used and accurate because ultrasound allows real-time visualization of the needle and injected contrast. Landmark-based injections would be advantageous, if they were accurate, because they would save the time and expense associated with ultrasound. However, few prospective studies have compared well-described landmark-based shoulder injection techniques without ultrasound. Question/purpose Using anatomic landmarks, and without using ultrasound, is the accuracy of glenohumeral injection for adhesive capsulitis greater via the posterior approach or via a new anterior approach? Methods Between 2018 and 2020, we treated 108 patients potentially eligible for adhesive capsulitis treatment. These patients had clinical symptoms of aggravating shoulder pain with a duration of less than 4 months and passively impaired, painful glenohumeral ROM. Due to the exclusion of patients with other shoulder conditions (full-thickness rotator cuff ruptures and posttraumatic stiffness), 95 patients received an injection in this sequential, prospective, comparative study. Between 2018 and 2019, 41 patients (17 males and 24 females; mean age 52 ± 5 years; mean BMI 24 ± 3 kg/m2) were injected through the posterior approach, with the acromion as the anatomical landmark, during the first part of the study period. After that, between 2019 and 2020, 54 patients (20 males and 34 females; mean age 54 ± 4 years; mean BMI 23 ± 3 kg/m2) received an injection through a new anterior approach, with the acromioclavicular joint as the anatomic landmark, during the second part of the study period. Injections via both approaches were administered by two experienced shoulder specialists (both with more than 10 years of experience). Both specialists had experience with the posterior approach before this study, and neither had previous training with the new anterior approach. Injections contained a corticosteroid, local anaesthetic, and contrast medium. Radiographs were taken within 20 minutes after the injection, and a radiologist blinded to the technique determined accuracy. Accurate injections were defined as having contrast fluid limited to the glenohumeral joint, while inaccurate injections displayed leakage of contrast fluid into the soft tissue or subacromial space. All of the enrolled patients were analyzed. Results In the group with the posterior approach, the accuracy was 78% (32 of 41) in contrast to 94% (51 of 54, odds ratio 0.21 [95% CI 0.05 to 0.83]; p = 0.03) in patients with the new anterior approach. Conclusion The new anterior approach without the use of ultrasound was more accurate than the posterior approach. In fact, it was nearly as accurate as previously published ultrasound-guided approaches. We recommend using the new anterior approach for intraarticular glenohumeral injections instead of ultrasound-guided injections because it will save time and costs associated with ultrasound. Still, the clinical effects (anxiety, pain, functional outcome, and adverse events) of the new anterior approach should be compared with ultrasound-guided injections in a randomized study. Level of Evidence Level II, therapeutic study.

Comparison of Outcomes of Two Different Corticosteroid Injection Approaches for Primary Frozen Shoulder: A Randomized Controlled Study

“…Combined with the cost of time and money due to ultrasound-guided injection, it remains controversial whether ultrasound-guided technology is worth recommending ( 24 , 25 ). The current study used a modified AA for injection without ultrasound guidance, which has been proven to have the same accuracy for the glenohumeral joint as the standard PA ( 13 ). Using the acromioclavicular joint as a reference, this approach can accurately and quickly complete the injection process.…”

“…Anterior approach group. As described by Rijs et al ( 13 ), the patient was placed in the sitting position, the upper limb was placed on the thigh on the same side and rotated outward as much as possible, and the elbow joint was placed in the flexion position. The in vitro anatomical landmarks of the shoulder joint were touched in order, and the coracoid process, the inner and outer edges of the acromion, the anterolateral angle of the acromion, the spine of the scapula and the acromioclavicular joint were marked with a pen.…”

“…In 2020, Elnady et al ( 12 ) proposed that, for frozen shoulders, ultrasound-guided hydrodilatation through the AA is practically and functionally more effective than the traditional PA. In 2021, Rijs et al ( 13 ) also proved in a prospective trial that, after injecting contrast agent into the glenohumeral joint through the AA and PA without ultrasound guidance, the accuracy of the AA was higher than that of the PA. However, there have been no prospective clinical studies comparing the clinical effects of the AA and PA ( 13 ).…”

“…In 2021, Rijs et al ( 13 ) also proved in a prospective trial that, after injecting contrast agent into the glenohumeral joint through the AA and PA without ultrasound guidance, the accuracy of the AA was higher than that of the PA. However, there have been no prospective clinical studies comparing the clinical effects of the AA and PA ( 13 ).…”

CORR Insights®: Is the Anterior Injection Approach Without Ultrasound Guidance Superior to the Posterior Approach for Adhesive Capsulitis of the Shoulder? A Sequential, Prospective Trial

“…The current sequential prospective study by Rijs et al [11] demonstrated an effective technique for intraarticular corticosteroid injections for adhesive capsulitis without the aid of imaging. The authors studied 95 patients comparing a new anterior approach versus posterior approach for intraarticular injections using anatomic landmarks by two experienced surgeons.…”