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Ultrasound · Shoulder

Glenohumeral Joint Injection (Anterior Rotator Interval)

shoulderglenohumeralanteriorrotator intervalbiceps

Treats

  • Glenohumeral osteoarthritis or synovitis
  • Adhesive capsulitis
  • Diagnostic intra-articular anesthesia
  • Convenient anterior alternative when combining with biceps tendon sheath injection

Contraindications

  • Active local skin infection or cellulitis at the entry site (absolute)
  • Suspected septic joint (absolute — aspirate first)
  • Bacteremia (absolute for joint injection)
  • Known allergy to local anesthetic, steroid, or antiseptic prep
  • Therapeutic anticoagulation — review case-by-case
  • Uncontrolled diabetes (relative)

Pre-procedure checklist

  • Confirm patient identity (two identifiers)
  • Confirm procedure, side, and site — mark with patient awake
  • Review allergies and anticoagulation
  • Confirm informed consent
  • Pre-scan to confirm depth and Doppler the AHC artery branches
  • Time-out immediately before needle entry

Positioning

  • Supine; head elevated ~30°; arm relaxed
Positioning

Probe

  • High-frequency linear probe (6-13 MHz)
Probe

Landmarking — find the view

  • Place probe transversely over anterior shoulder to locate the bicipital groove with the long head of the biceps.
  • Rotate into long-axis of the biceps tendon.
  • Tilt slightly cephalad to visualize the rotator interval and capsule above the tendon.

The correct ultrasound view

  • Long-axis view at the groove entrance: biceps tendon fibers with the thin rotator-interval capsule above and a potential dark joint space deep to the capsule
The correct ultrasound view

Needle corridor

  • Under rotator-interval capsule (above) along humeral head/neck (below)
Needle corridor

Avoid

  • Ascending branch of the anterior humeral circumflex artery (runs transverse across the bicipital groove — Doppler before every entry)
  • Cephalic vein (medial deltopectoral groove)
  • Musculocutaneous nerve (enters coracobrachialis 3–8 cm distal to the coracoid process — stay lateral to the coracoid at all times)
  • Brachial plexus and axillary vessels (medial to the coracoid — confirm needle entry point is lateral to the coracoid process)
  • Intratendinous subscapularis or long head biceps placement

Steps

  1. 1Advance in-plane beneath capsule into joint; confirm flow along intra-articular biceps; inject planned volume slowly.
  2. 2STOP IMMEDIATELY if the patient reports electric, shooting, or paresthetic sensations — withdraw and reposition.

Tips

  • The anterior rotator interval approach does not reliably traverse the SASD bursa — if treating both bursa and GH joint, perform sequential injections.
  • Limit corticosteroid to ≤ 3 per joint per year.
  • If color Doppler shows the AHC artery in the planned path, abandon and re-plan.

Resident pearls

  • Identify the coracohumeral ligament; the target is deep to this structure.

Supplies

  • 10 mL Syringe
  • 22G 1.5" Needle (standard); 22G 2.5-3.5" spinal if pre-scan shows rotator interval depth > 3 cm
  • 18G Drawing Needle
  • 1% Lidocaine (5-10 mL)
  • Triamcinolone 40 mg OR Dexamethasone 4-10 mg
  • Alcohol Swabs (vial tops)
  • Betadine/Chloraprep
  • Sterile Gloves
  • Sterile 4x4 Gauze Pads
  • Sterile Towels & Drapes
  • Adhesive Bandage (Band-Aid)
  • Washcloth/Towel (gel cleanup)
  • Needle Disposal Safety Cap
  • Sterile probe cover & gel

Post-procedure

  • Apply a clean dressing; remove after 24 hours.
  • Local anesthetic relief for 1-4 hours; steroid begins 24-72 hours.
  • Steroid 'flare' in 2–10% — manage with ice and acetaminophen.
  • Rest 24-48 hours.
  • Return immediately for: spreading redness, swelling, fever, or disproportionate pain.
  • Diabetics: expect 50-100 mg/dL glucose rise for 3-5 days.
  • Maximum 3 injections per joint per year.