The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 16

Scientific Articles | August 15, 2012

Injection of the Subacromial Bursa in Patients with Rotator Cuff Syndrome: A 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, CaliforniaA commentary by James E. Tibone, MD, is linked to the online version of this article at jbjs.org.

J Bone Joint Surg Am, 2012 Aug 15;94(16):1442-1447. doi: 10.2106/JBJS.K.00534

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Abstract

Background:

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.

Methods:

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.

Results:

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).

Conclusions:

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.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion

Rotator cuff syndrome is a common musculoskeletal condition for which patients often seek medical attention^1-4. A mainstay of both the diagnosis and the treatment of rotator cuff tendinopathy is injection into the subacromial bursa. The therapeutic benefits of injection of corticosteroid into the subacromial bursa have been studied in comparison with other forms of treatment, including oral indomethacin therapy⁵, injection of local anesthetic alone^6,7, subacromial injection of tenoxicam⁸, and remote, intramuscular injection of corticosteroid⁹. Less attention, however, has been focused on the accuracy of performing intrabursal injection relying on palpation of the physical boundaries of the acromion. Recognizing that the effectiveness of an injection may hinge on the precise delivery of therapeutic medication into the area of abnormality^10,11 and considering the different routes of bursal injection utilized by medical practitioners (anterior, lateral, and posterior), it is important to determine whether or not the subacromial bursa can be injected in the clinical setting with a reasonable degree of success. Furthermore, when there are various routes of injection, it is important to determine if there is equivalent accuracy.

In previous clinical studies, the rate of success of subacromial injection has ranged from 29% to 87%^10,12-15. Partington and Broome¹⁶ demonstrated an accuracy of 83% in a cadaver model. In light of these data, some authors have recommended the use of ultrasound as an adjunctive guide to increase the success of subacromial injection^11,17, although one recent study showed no added benefit of ultrasound guidance over injection based on anatomical landmarks¹⁸.

In the present study, we hypothesized that there were no differences in the accuracy rates associated with the anterior, lateral, and posterior routes for injection of the subacromial bursa in patients with rotator cuff syndrome.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion

This prospective, randomized clinical trial was conducted under the auspices of the institutional review board of our hospital, and all participants gave written informed consent. This clinical trial is published on the ClinicalTrials.gov public site (registry number NCT01330641).

Study Participants and Randomization Process

We chose a sample size of twenty-five patients per group to use normal approximation to the binomial distribution, assuming that the accuracy for each injection site would be between 70% and 80% on the basis of previously published studies^14,16. The total sample size of seventy-five provided a power of 95% to detect a 10% difference between the different routes of bursal injection¹⁹.

Seventy-five shoulders in seventy-five patients were enrolled in this study, which spanned an eighteen-month period of time from 2008 to 2010. Pain with overhead shoulder activity, night pain, and a positive impingement sign were the predominant clinical findings. Patients were excluded if they were pregnant, had an allergy to any of the injection agents, had undergone prior shoulder surgery, were receiving anticoagulation therapy, or had either diabetes or renal disease. In addition, in an effort to exclude patients with a possible full-thickness rotator cuff tear on the basis of clinical findings alone, we excluded patients who manifested >1 grade of muscle weakness of shoulder flexion and/or external rotation, recognizing that some patients may have been excluded unnecessarily because they manifested pain-induced muscle weakness.

Factor Assessment

Age, sex, body mass index (BMI) as calculated from height and weight measured at the time of the office visit, shoulder involvement, and acromial anatomy were assessed. Outlet-view radiographs of the shoulder were used to describe acromial type on the basis of the acromial angle in the sagittal plane as Type I (0° to 12°), Type II (13° to 27°), or Type III (>27°)²⁰ as well as acromial tilt, which referenced acromial inclination to the x axis of the glenoid²¹. In addition, with use of anteroposterior radiographs, the slope of the acromion in relation to the axis of the lateral aspect of the clavicle in the coronal plane was measured as either neutral (0° to 10° of angulation) or downward-sloping (>10° of angulation)²².

Subjects were assigned to an injection group with use of a random-number-calculator program. The assigned patient-identification numbers (1 to 75) with the attached randomly sorted injection routes (A = anterior, B = posterior, and C = lateral) were placed in opaque envelopes so that the surgeon performing the injection would not know the randomly assigned injection route until after the patient had signed the informed-consent form for the study.

Injection Procedures

Injection was performed with the patient sitting and the arm distracted by gravity. One physician performed all injections. Prior to the start of the study, the physician who was to perform the injections for the study completed ten injections each with use of lateral and anterior approaches in patients who were not involved in the study to familiarize himself with these approaches because, prior to the study, he had predominantly performed subacromial injections with use of a posterior approach.

After sterile preparation of the site, a topical spray anesthetic was applied, followed by subacromial injection with use of a 5-cm, 21-gauge needle connected to a 10-mL syringe containing 5 mL of 1% lidocaine, 2 mL of iopamidol injection contrast medium, and 1 mL (40 mg) of triamcinolone. Anterior injection was performed immediately inferior to the anterior edge of the acromion, starting at the depression immediately lateral to the acromioclavicular joint and with the needle being aimed cephalad and slightly lateral. Lateral injection was performed just inferior to the midlateral aspect of the acromion, with the needle being angled slightly cephalad. Posterior injection was performed immediately inferior and medial to the posterolateral corner of the acromion, with the needle being angled cephalad along the undersurface of the acromion toward the anterior edge of the acromion, which was palpated by the other hand of the injecting surgeon. For all routes of injection, if bone was contacted, the needle was withdrawn slightly in order to achieve injection without resistance.

Outcome Measures

The primary outcome of interest was the accuracy of injection into the bursa. Subjects were instructed to perform normal movement of the shoulder and, approximately ten minutes after injection, two perpendicular radiographs of the shoulder (anteroposterior and outlet views) were made. A single musculoskeletal radiologist who was blinded to the injection route and other patient-related data subsequently interpreted all of the radiographs. The injections were classified as either intrabursal (Fig. 1) or extrabursal. Extrabursal injection was further subdivided as within the deltoid muscle, subcutaneous, or intra-articular.

Fig. 1

Anteroposterior (Fig. 1-A) and outlet (Fig. 1-B) radiographs showing an accurately injected bursa. The outlet view shows more voluminous bursa anterior to the acromion (black arrows) with tapering to a ribbon-like space at its posterior boundary (white arrows).

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An additional outcome of interest was the change in the pain level. Prior to injection, the patient was asked to record the level of pain with use of an 11-point visual analog scale (VAS) (with 0 indicating no pain and 10 indicating maximum pain)²³. Between thirty minutes and one hour after injection, after exercising the arm, the patient was asked again to record the level of pain.

Statistical Analysis

We compared the injection accuracy for each route with use of the chi-square test. To add interpretability, we calculated the relative accuracy (also known as relative risk [RR]) along with its significance with use of Poisson regression. Binary outcomes in cohort studies are commonly analyzed by applying a logistic regression model to the data to obtain odds ratios (OR) for comparing groups with different sets of characteristics. When the outcome event is common, however, it is often more desirable to estimate the RR^24-27 as there is an increasing differential between the RR and the OR with increasing incidence rates and there may be a tendency to misinterpret the OR as if it were the RR. The potential of overestimated error for the RR when applied to binomial data²⁸ was rectified with use of a robust error variance procedure^25,29. Fit of the model was assessed by calculating deviance and Pearson chi-square statistics.

Source of Funding

There was no external funding for this study.

Results

Introduction | Materials and Methods | Results | Discussion

The study group included thirty-five male and forty female patients with a mean age of fifty-four years (range, twenty-four to seventy-six years). No patient experienced any complication following injection. Patient characteristics (age, sex, BMI, and shoulder side) were described for the three routes of injection (Table I).

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TABLE I Patient Characteristics

Characteristic	Posterior Route	Anterior Route	Lateral Route
Number of patients*	25 (100%)	25 (100%)	25 (100%)
Female*	16 (64%)	13 (52%)	11 (44%)
Right arm*	12 (48%)	16 (64%)	11 (44%)
Age†(yr)	55.4 ± 11.4	52.2 ± 9.5	53.1 ± 12.2
BMI†(kg/m2)	27.6 ± 4.6	27.9 ± 5.9	29.3 ± 5.9
BMI >30*	8 (32%)	10 (40%)	8 (32%)

*The values are given as the number of patients, with the percentage in parentheses.
†The values are given as the mean and the standard deviation.

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TABLE I Patient Characteristics

Characteristic	Posterior Route	Anterior Route	Lateral Route
Number of patients*	25 (100%)	25 (100%)	25 (100%)
Female*	16 (64%)	13 (52%)	11 (44%)
Right arm*	12 (48%)	16 (64%)	11 (44%)
Age†(yr)	55.4 ± 11.4	52.2 ± 9.5	53.1 ± 12.2
BMI†(kg/m2)	27.6 ± 4.6	27.9 ± 5.9	29.3 ± 5.9
BMI >30*	8 (32%)	10 (40%)	8 (32%)

*The values are given as the number of patients, with the percentage in parentheses.
†The values are given as the mean and the standard deviation.

Injection Accuracy

The accuracy of injection varied significantly among the three injection routes (p = 0.006; chi-square test), with a rate of 56% (fourteen of twenty-five) for the posterior route, 84% (twenty-one of twenty-five) for the anterior route, and 92% (twenty-three of twenty-five) for the lateral route (Table II). We further evaluated whether the anterior and lateral routes were significantly more accurate than the posterior route on the basis of the Poisson regression model. With use of the chi-square test, the injection route was significantly associated with accuracy in the Poisson model (p = 0.03). Both deviance and the Pearson chi-square test supported goodness-of-fit of the model. In Table III, the relative accuracy is presented along with its 95% confidence intervals. Compared with posterior injection, injection accuracy (also known as RR) was 1.6 times greater for lateral injection (p = 0.008) and 1.5 times greater for anterior injection (p = 0.04). When the reference group was anterior injection, this Poisson model revealed that the RR for lateral injection was not significant (95% CI for RR, 0.89 to 1.35; p = 0.39) (data not shown in Table III). Qualitatively, no notable differences in successfully injected bursae were observed. Of the seventeen extrabursal injections, twelve were intradeltoid, three were intra-articular, and two were in subcutaneous tissue.

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TABLE II Accuracy of Subacromial Injection by Route

Injection Route	Accuracy of Subacromial Injection*
Posterior	56% (14 of 25)
Anterior	84% (21 of 25)
Lateral	92% (23 of 25)
Overall	77% (58 of 75)

*The accuracy of injection varied significantly among the three injection routes (p = 0.006; chi-square test).

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TABLE II Accuracy of Subacromial Injection by Route

Injection Route	Accuracy of Subacromial Injection*
Posterior	56% (14 of 25)
Anterior	84% (21 of 25)
Lateral	92% (23 of 25)
Overall	77% (58 of 75)

*The accuracy of injection varied significantly among the three injection routes (p = 0.006; chi-square test).

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TABLE III Relative Accuracy for the Three Injection Routes

Injection Route	Relative Accuracy*†	P Value
Posterior (base)	—	—
Anterior	1.50 (1.02 to 2.22)	0.04
Lateral	1.64 (1.14 to 2.38)	0.008

*The 95% confidence interval is given in parentheses.
†The relative accuracy of anterior and lateral routes of injection is calculated in reference to the posterior route of injection.

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TABLE III Relative Accuracy for the Three Injection Routes

Injection Route	Relative Accuracy*†	P Value
Posterior (base)	—	—
Anterior	1.50 (1.02 to 2.22)	0.04
Lateral	1.64 (1.14 to 2.38)	0.008

*The 95% confidence interval is given in parentheses.
†The relative accuracy of anterior and lateral routes of injection is calculated in reference to the posterior route of injection.

Analysis of acromial type in the sagittal plane revealed a Type-I acromion in twenty-six shoulders (35%), a Type-II acromion in forty-two shoulders (56%), and a Type-III acromion in seven shoulders (9%). The average acromial tilt was 23.7° (range, 11° to 39°). Slope in the coronal plane was neutral for sixty-five acromions (87%) and downward-sloping for ten (13%). No correlation was found between these radiographic measurements of acromial anatomy and the accuracy of subacromial injection or patient sex.

Effect of Sex

The accuracy of injection was significantly lower in females than in males (p < 0.006; chi-square test). For females, injection accuracy was significantly lower with use of the posterior route (38%) as compared with the anterior route (77%) (p = 0.047) and the lateral route (91%) (p = 0.009) (Fig. 2). In contrast, among male patients, injection accuracy was similar between the three injection routes (89% for the posterior route, 92% for the anterior route, and 93% for the lateral route).

Fig. 2

Bar graph showing the rate of accuracy of subacromial injection in males and females according to the route of injection.

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Pain Reduction According to Injection Accuracy

With use of the VAS scores before and within one hour after injection, the degree of pain reduction was compared according to the accuracy of injection. With successful intrabursal injection, 33% (nineteen) of fifty-eight patients reported complete relief of pain after injection (VAS score = 0), whereas zero of seventeen patients with an extrabursal injection reported complete relief of pain after injection. The mean VAS score was improved nearly 5 points with intrabursal injection as compared with an improvement of 3 points with extrabursal injection. This 2-point improvement with intrabursal injection was significant (p < 0.001) and was greater than the minimal clinically important difference for the VAS score in patients with rotator cuff disease³⁰.

Discussion

Introduction | Materials and Methods | Results | Discussion

The anterior and lateral approaches were statistically comparable in terms of accuracy when physical landmarks were used to determine the placement of subacromial bursal injection. The posterior route was significantly less accurate. To our knowledge, this difference has not been reported previously in the literature. While most studies have used one or two routes of injection to evaluate the success of bursal injection, we are aware of only one previous study that prospectively evaluated the anterior, lateral, and posterior injection routes¹⁴. The authors of that study found no differences between the posterior, anterior, and lateral injection routes, reporting an overall accuracy rate of 70%. On the basis of our review, that study of fifty-eight patients may not have had sufficient statistical power to detect differences between the routes of injection.

While BMI did not influence the accuracy of injection, other explanations for our finding of lower accuracy for posterior injection of the subacromial bursa could include faulty injection technique, insufficient needle length, and anatomy of the acromion and subacromial bursa. As only one physician performed the injections, it is conceivable that faulty technique could explain the observed differences in injection accuracy and that the use of a different physician or multiple physicians to inject the subacromial bursa may have produced a different outcome. Sardelli and Burks³¹ measured the distances of the anterior, lateral, and posterior injection routes of the subacromial bursa in patients undergoing arthroscopy of the shoulder and found that the length of the needle necessary to enter the bursa was 5 cm for the posterior route, compared with only 3 cm for both the anterior and lateral routes. Those authors believed that fluid extravasation into the subacromial area from glenohumeral arthroscopy may have incorrectly increased the observed distances to the bursa, although the proportionate differences between injection routes would not have been affected. The needles in the present study had a length of 5 cm, and this factor may have affected our ability to inject the bursa from a posterior route in some patients.

In the present study, acromial type, tilt, and slope anatomy were not correlated with the accuracy of bursal injection. In addition, we noted no differences in the distribution of acromial morphology between males and females that might account for the noted differences in accuracy of the posterior injection route. Mallon et al.³², in a detailed study of scapulae, showed high variability in the acromial angle and the supraspinatus outlet such that radiographic parameters for impingement were difficult to formulate. Tuite et al.³³ and MacGillivray et al.²² showed that acromial angles were not different between male and female patients with rotator cuff syndrome. Thus, it seems unlikely that acromial morphology would account for the differences in the accuracy of bursal injection that we found.

We believe that the anatomic and pathologic features of the subacromial bursa are the most plausible explanation for the findings of our study. As described by Strizak et al.³⁴, the subacromial bursa “sits atop the rotator cuff like the cap of a mushroom or a beret.” The bursa is located predominantly beneath the anteriorly situated coracoacromial arch (formed by the coracoacromial ligament and the anterior aspect of the acromion), with a major portion of the bursa extending laterally beyond the margin of the acromion. Strizak et al. showed that the bursa had minimal extension posterior to the acromion. Moreover, they described the roof of the bursa as being firmly adherent to the underside of the acromion. In another study, Beals et al.³⁵ confirmed that the subacromial bursa occupied the area beneath the most anterior portion of the acromion without extension to the posterior aspect of the acromion. The findings of those studies are consistent with what we observed radiographically in our patients with intrabursal injection (Fig. 1). In addition, Strizak et al.³⁴ found that although the normal subacromial bursa accepted 5 to 10 mL of volume, abnormal bursae had thickening and edema of the walls of the bursa and accepted less volume during injection. Although those authors did not describe any differences in bursal anatomy between the sexes, it seems plausible that if the bursae in females are smaller and if the bursae themselves are abnormal, as might be found in patients with longstanding subacromial disease, the target area for injection would be reduced. This fact, together with the anatomic finding of reduced volume at the posterior boundary of the bursa^34,35 (Fig. 1), might explain the lower rate of successful injection seen in females when the posterior route was used.

Similar to other investigators^10,13,36, we found that patients with documented intrabursal injection had greater initial pain relief. Although intrabursal injection accompanied by complete relief of pain in the first hour after injection may be construed as evidence of a successful intrabursal injection, the failure to appreciably reduce pain levels after injection may imply an incorrect diagnosis or the failure to inject the bursa. Early-onset pain relief of a lesser degree following extrabursal injection may be due to either a placebo benefit or the spreading effect of the local anesthetic.

The major strengths of the present study include true randomization of patients and sufficient statistical power to address the hypothesis. The present study did have several limitations. It was not designed to address either the interobserver interpretation of subacromial bursography and acromial morphology or the accuracy of bursal injection as performed by multiple practitioners. We found a difference in the accuracy of posterior injection related to sex. However, because this was not a preplanned hypothesis, the findings should be interpreted within this limitation.

In conclusion, our data support subacromial injection in the office setting with use of either the anterior or lateral route.

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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.

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drug administration routes ; rotator cuff ; acromion ; subacromial bursa ; subacromial injection

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Richard A. Marder, Sunny H. Kim, Jerry D. Labson, John C. Hunter; Injection of the Subacromial Bursa in Patients with Rotator Cuff SyndromeA Prospective, Randomized Study Comparing the Effectiveness of Different Routes. The Journal of Bone & Joint Surgery. 2012 Aug;94(16):1442-1447.

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