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Injection of the Subacromial Bursa in Patients with Rotator Cuff SyndromeA Prospective, Randomized Study Comparing the Effectiveness of Different Routes
Richard A. Marder, MD1; Sunny H. Kim, PhD2; Jerry D. Labson, MD3; John C. Hunter, MD4
1 Department of Orthopaedic Surgery, University of California-Davis Medical Center, 2805 J Street, Suite 300, Sacramento, California 95816. E-mail address: richard.marder@ucdmc.ucdavis.edu
2 Public Health Sciences, University of California-Davis School of Medicine, 2921 Stockton Boulevard, Suite 1400, Sacramento, CA 95817
3 101 Bodin Circle, Travis AFB, CA 94535
4 Department of Radiology, University of California-Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, California 95816
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Investigation performed at the Sports Medicine Center, University of California-Davis Health System, Sacramento, California

A commentary by James E. Tibone, MD, is linked to the online version of this article at jbjs.org.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Aug 15;94(16):1442-1447. doi: 10.2106/JBJS.K.00534
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Rotator cuff syndrome is often treated with subacromial injection of corticosteroid and local anesthetic. It has not been established if the common injection routes of the bursa are equally accurate.


We conducted a prospective clinical trial involving seventy-five shoulders in seventy-five patients who were randomly assigned to receive a subacromial injection through an anterior, lateral, or posterior route with respect to the acromion. An experienced physician performed the injections, which contained radiopaque contrast medium, corticosteroid, and local anesthetic. After the injection, a musculoskeletal radiologist, blinded to the injection route, interpreted all of the radiographs.


The rate of accuracy varied with the route of injection, with a rate of 56% for the posterior route, 84% for the anterior route, and 92% for the lateral route (p = 0.006; chi-square test). The accuracy of injection through the posterior route was significantly lower than that through either the anterior or the lateral route (p < 0.05 for both comparisons; Poisson regression). In addition, the accuracy of injection was significantly lower in females than in males (p < 0.006; chi-square test). Among males, no differences between the routes were noted (with accuracy rates of 89% for the posterior route, 92% for the anterior route, and 93% for the lateral route). Among females, however, the accuracy of injection was lower for the posterior route than for either the anterior or the lateral route (with accuracy rates of 38% for the posterior route, 77% for the anterior route, and 91% for the lateral route) (p < 0.05).


The anterior and lateral routes of subacromial bursal injection were more accurate than the posterior route. The accuracy of subacromial bursal injection was significantly different between males and females, mainly because of a lower accuracy of bursal injection with use of the posterior route in females. The present study suggests that the posterior route is the least accurate method for injection of the subacromial bursa in females.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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