eMedicine Specialties > Clinical Procedures > Musculoskeletal Procedures

Arthrocentesis, Shoulder

Stephen Kishner, MD, MHA, Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans
Jaimie A Clodfelter, DO, Resident Physician, Department of Physical Medicine and Rehabilitation, Louisiana State University Health Science Center; Brett J Rothaermel, MD, PT,, Staff Physician, Department of Physical Medicine and Rehabilitation, Louisiana State Health Science Center

Updated: Jul 21, 2009

Introduction

Shoulder arthrocentesis can be performed diagnostically for identification of the etiology of acute arthritis or therapeutically for drainage of an effusion. Using the same technique, the joint can be injected therapeutically with corticosteroids, anesthetics, or both.

The practitioner performing the procedure should be familiar with the anatomy of the glenohumeral joint and surrounding structures in order to avoid complications. The glenohumeral joint of the shoulder is formed by the humeral head and the glenoid fossa of the scapula. It is bounded by the acromion. The subdeltoid bursa lies under the deltoid muscle and covers the lateral and superior aspect of the proximal humerus. The neurovascular bundle lies medially in the axilla.

Aspiration of the glenohumeral joint can be accomplished from an anterior or posterior approach. The posterior approach allows the patient to be blinded from the procedure, and it mimics the approach used in arthroscopy of the joint.

Indications

Diagnostic injection of anesthetic (with or without corticosteroid) into the glenohumeral joint to determine if it is the source of the patient's pain
Therapeutic injection to provide pain relief and functional improvement in glenohumeral osteoarthritis, rheumatoid arthritis, or adhesive capsulitis (This may be performed through drainage of an effusion, septic joint, or hemarthrosis or through instillation of medication.)
Joint aspiration to aid in the diagnosis of the underlying pathologic process through synovial fluid analysis¹

Contraindications

Bacteremia, cellulitis of overlying skin, and adjacent osteomyelitis are often considered absolute contraindications because of the potential risk of seeding the joint with bacteria. In these situations, the procedure should only be performed the clinician strongly suspects septic arthritis as the cause of overlying inflammatory changes, and then only after consultation with an orthopedist.
Relative indications include glenohumeral joint infection, chronic infection distant to injection site, allergy to injectate, diabetes mellitus, or uncontrolled coagulopathy.

Anesthesia

Local anesthesia is recommended. For more information, see Local Anesthetic Agents, Infiltrative Administration.
After skin preparation and identification of the needle insertion site, use a 25-gauge needle to make a small skin wheal with local anesthetic into the subcutaneous tissue and then along the anticipated needle pathway.

Equipment

Alcohol sponges
Skin cleansing agent (chlorhexidine [Hibiclens] or povidone-iodine [Betadine])
Gauze
Gloves (clean unsterile gloves sufficient if no contact made with skin or needle)
Needles - 1.5-inch, 25-gauge for anesthetic injection and 18-22 gauge for aspiration; spinal needle may be needed for obese or muscular patients
Syringes - 3-5 mL for anesthetic injection and 5-20 mL for aspiration
Local anesthetic
Specimen tubes
Corticosteroid
Bandage

Positioning

The patient should be seated in a comfortable position.
For the anterior approach, rest the patient’s hand on his or her lap so the shoulder is internally rotated.
For the posterior approach, place the patient’s hand on the contralateral shoulder.

Technique

Obtain informed consent.
Palpate and mark injection site depending on the approach chosen (see different approaches below)
Sterilize the skin surrounding the injection site and allow it to dry.
Locally anesthetize with a 25-gauge needle and a 3- or 5-mL syringe.
Insert an 18-gauge needle and aspirate on needle advancement into the joint space until synovial fluid is obtained.
If warranted, exchange syringe with corticosteroid-filled syringe and inject.
Remove needle and apply pressure and bandage.
Divide the fluid among the specimen tubes.

Anterior approach

Palpate the coracoid process and the humeral head. As the arm is internally rotated, the joint space can be felt as a groove lateral to the coracoid process.²

The circle represents the coracoid process.
Insert the needle medial to the head of the humerus and just below the tip of the coracoid process.

Insert the needle medial to the head of the humerus and just below the tip of the coracoid process.
Direct the needle slightly laterally and superiorly into scapulohumeral joint space.³

Direct the needle slightly laterally and superiorly.

Posterior approach

Insert the needle 1-2 cm inferior and medial to the posterior tip of the acromion.
Direct the needle anteriorly and medially toward the coracoid.⁴

Pearls

Take care to not direct the needle medially into the axillary neurovascular structures.
Do not inject with corticosteroid if joint infection is suspected.
If the fluid appears infected, send it for culture and sensitivity and treat the patient appropriately for the infection.
In general, joints should not be injected with corticosteroids more than 3-4 times per year.

Complications

Complications are uncommon and often insignificant but include the following:
- Hematoma and intravascular injection are possible because of the close proximity of the axillary vessels.
- Iatrogenic infection is possible. The risk of inducing joint infection is low when sterile technique is used.
- Injection of corticosteroids directly into a tendon or tendon insertion can sometimes result in tendon rupture.
- Corticosteroids may cause a transient rise in blood glucose levels in patients with diabetes mellitus.

Multimedia

Media file 1: The circle represents the coracoid process.

Media file 2: Insert the needle medial to the head of the humerus and just below the tip of the coracoid process.

Media file 3: Direct the needle slightly laterally and superiorly.

References

Lin HM, Learch TJ, White EA, Gottsegen CJ. Emergency joint aspiration: a guide for radiologists on call. Radiographics. Jul-Aug 2009;29(4):1139-58. [Medline].
Walsh NE, Rogers JN. Injection procedures. In: DeLisa JA, Gans BM, Walsh, eds. Physical Medicine & Rehabilitation: Principles and Practice. 4^th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:Chapter 14.
Partin WR. Emergency procedures. In: Stone CK, Humphries RL, eds. Current Diagnosis & Treatment: Emergency Medicine. 6^th ed. The McGraw-Hill Companies; 2008:Chap 6.
Braddom R. Peripheral joint, soft tissue and spinal injection technique. In: Bushbacher R, et al, eds. Physical Medicine & Rehabilitation. 3^rd ed. Philadelphia, PA: Elsevier Inc; 2007:541-562. [Full Text].
Fields TR, Berman JR. Arthrocentesis, Intraarticular Injection and Synovial Fluid Analysis. In: Paget SA, Gibofsky A, Beary JF, Sculco TP. Hospital for Special Surgery Manual of Rheumatology and Outpatient Orthopedic Disorders. 5^th ed. 2005:8.
Reichman EF, Waddell R. Arthrocentesis. Access Emergency Medicine. Available at http://www.accessem.com/content.aspx?aid=52306. Accessed October 20, 2008.
Sweiss N, Millstein ES, Primus G, et al. Aspiration Techniques and Indications for Surgery, Septic Arthritis. eMedicine from WebMD. Updated April 1, 2009. Available at http://emedicine.medscape.com/article/1268807-overview. Accessed October 15, 2008.

Keywords

shoulder arthrocentesis, glenohumeral arthrocentesis, shoulder injection, glenohumeral injection, steroid injection, corticosteroid injection, aspiration, joint aspiration, synovial fluid aspiration, adhesive capsulitis, osteoarthritis, rheumatoid arthritis, monoarticular arthritis, effusion, anterior approach, posterior approach

Contributor Information and Disclosures

Author

Stephen Kishner, MD, MHA, Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans
Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jaimie A Clodfelter, DO, Resident Physician, Department of Physical Medicine and Rehabilitation, Louisiana State University Health Science Center
Jaimie A Clodfelter, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Brett J Rothaermel, MD, PT,, Staff Physician, Department of Physical Medicine and Rehabilitation, Louisiana State Health Science Center
Brett J Rothaermel, MD, PT, is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Orleans Parish Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

For more information

Berman JR, Fields TR, Stern R. Arthrocentesis, Intraarticular Injection and Synovial Fluid Analysis. In: Paget SA, Gibofsky A, Beary JF. Hospital for Special Surgery Manual of Rheumatology and Outpatient Orthopedic Disorders. 5th ed. Lippincott Williams & Wilkins; 2005: Chapter 8.

Further Reading