Tendonitis, more properly termed tendinosis, results from acute or chronic stress of the rotator cuff tendons. Rotator cuff impingement results from repeated irritation of the rotator cuff beneath the acromial arch. 20 Repetitive overhead reaching and weight training are frequent precipitants of rotator cuff tendinosis and impingement. Rotator cuff tendinosis is diagnosed by eliciting pain or weakness with stress testing of the rotator cuff muscles. There are two common tests used for diagnosis of impingement. The Hawkins' test elicits pain with the shoulder passively flexed to 90 degrees and internally rotated. 21 The Neer's test elicits pain with passive abduction of the shoulder to 180 degrees. 22 Radiographs, if obtained, may show calcific deposits in the subacromial space or at the insertion of the supraspinatus tendon to the greater tuberosity. In cases of impingement, curvature of the acromion process may be seen.
The steroid injected reduces swelling and inflammation of tissues in the joint or bursa, which may reduce pain, other symptoms caused by tissue inflammation, irritation, or swelling. The procedure is performed under live x ray (fluoroscopy) and with the use of x ray dye to ensure accuracy and precision. While you are lying on your back, your skin is cleaned with an antiseptic solution. You are monitored with a blood pressure cuff and a blood oxygen monitoring device which monitors your oxygen levels and heart rate. The injection consists of a mixure of local anesthetic (lidocaine) and steroid (methylprednisolone or Depo-medrol). Immediately after the injection, the skin is cleaned and a band-aid is applied. You may experience some “pressure” at the injection site and this may last up to an hour. Your pain may return and you may have some soreness at the injection site for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation from the steroid itself. You many want to apply ice to affected area. At about day #5 you should start noticing pain relief. It may take up to 2 weeks to notice an improvement from the steroids.
This should be preformed under ultrasound guidance, as the biceps tendon is deep under the thick deltoid and impossible to 'feel' with the needle. Injecting the biceps tendon with a proteolytic steroid can also increase the risk of tendon rupture. Therefore, we prefer to use a hyaluronan (Ostenil) in young patients.
The patient sits with their arm resting by their side. Due to the great variation in humeral version, the tendon position can only be judged by rotating the arm into the best position for injection and letting the patient rest it their. The LHB tendon and groove are identified and marked on the skin with a marker. The point of injection, just lateral to the ultrasound probe is marked. The needle is directed at a 45 degree angle in the long axis of the probe, heading towards the LHB sheath and tendon. The actual tendon is not injected but rather the swollen sheath around the tendon. The injected fluid can be seen to run into the sheath.