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What is going to be done and why?
You have been scheduled for a procedure called a “subacromial subdeltoid
steroid injection”. This is a both a diagnostic (to find the cause) and a therapeutic (to
treat) injection for patients with shoulder pain originating from the rotator cuff. First, we
should explain some details regarding shoulder anatomy.
Figure 1 Bones of the shoulder
Humerus - the arm bone!
Glenoid - the shoulder joint socket
Acromion - bony shelf that forms most of the roof of the joint
Scapula - the shoulder blade
The shoulder joint is a very shallow joint. This allows for a very large amount of motion
which is important; we need to move our arm in many directions. The downside of a
shallow joint, however, is that it is unstable. This is where the “rotator cuff” comes into
play. The rotator cuff is a group of 4 muscles and their tendons which attach to the end
of the arm bone. They wrap around the head of the bone and the shoulder joint and
add a greater amount of stability to the joint.
A tendon is a very tough tissue that connects a muscle to a bone. In the above
diagram, note that as the muscles get near to the arm bone, they begin to change to a
white color; this is the tendon of the muscle attaching to the bone. Every time the arm
moves, the tendons also move, sometimes moving under hard bony surfaces.
Over a life time, these thousands of movements can lead to problems. The tendons
can degenerate (break down) and become chronically inflamed. This is called
“tendonosis”. This can lead to pain and over time, even partial or complete tears in the
tendons (rotator cuff tears). One of the tendons, the supraspinatus, has to move under
a bony shelf called the acromion which is why this is the most common tendon involved
in rotator cuff tendonosis.
Dark circle - subacromial space; the
space between the rotator cuff and
the acromion which forms the roof of
the joint
The thick lines with circles at their
end represent the four rotator cuff
tendons attaching to the head of the
arm bone
The one line above the subacromial
space is a ligament that forms the
rest of the “roof” of the joint
Figure 2 The rotator cuff and subacromial space
The rotator cuff tendons are covered completely by another large muscle, the deltoid
muscle. In between the rotator cuff tendons and the deltoid muscle is a small space
where an injection of anti-inflammatory medicine called “corticosteroid” can be placed.
We will be using a very thin needle similar in appearance to an acupuncture needle, and
the needle will be guided to the correct place using an ultrasound machine. Typically,
the procedure hurts much less than patients are anticipating, and it will take roughly 5
minutes to complete.
We will also order plain X-rays of your shoulder and also a diagnostic ultrasound exam.
These are screening tests. A screening test is a test that is easy to perform, usually
relatively inexpensive, and without much of a waiting time. These types of tests are a
good way to rapidly find problems that are not especially subtle, and so they will be
done first. An MRI scan will also be ordered, but if the screening tests come back
positive and we do not feel the MRI will change our treatment decisions, we will
consider canceling it.
What should I expect after my injection?
Since local anesthetic (numbing medication) will be injected along with the
corticosteroid, you may experience pain relief right after the procedure has been
completed. This will last a few hours. After this, many patients experience several days
of post-procedure discomfort until the anti-inflammatory begins to take effect on the 3rd
or 4th day. If your pain is not coming from the rotator cuff, you will not feel any relief at
all, and we will continue our search for other causes.
Since we are trying to see if this injection helps, it is important that you tell us exactly
what happens after it. It is important to remember that pain is not just a number. The
best way for us to get a sense of your pain is by you telling us how you feel when you
DO things. Do whatever activities reliably trigger your pain. If putting on your shirt or
coat is painful, do that. If you have trouble lifting your arm above your head or
scratching your back, try that as well. Many patients with shoulder pain have particular
trouble at night while sleeping, so keep track of whether you sleep better.
The more information about how you felt after the injection the better. Be very specific.
Tell us what used to happen when you did these things, and how it was different this
time. If certain parts of your arm felt much better, but other areas continued to hurt, tell
us that. And, if it didn’t help at all, tell us that as well. Remember, regardless of whether
the injection helps or not, it will give us more information about what your problem might
Then, write the information down so we can discuss it later, and do it right away
while you still can really remember exactly how you felt. Then send an email with this
information to Dr. Smith after 1 week has passed. The email address is
“[email protected]”.
We will also give you an appointment for another treatment in 6 weeks, and when you
come, please bring your notes and tell us what happened. Typically, we will do a total
of 2 injections six weeks apart, and then reassess how you are doing. If you get
significantly better, we may then recommend that you to begin performing physiotherapy
to further rehabilitate the shoulder. While this is all happening, we will have already
ordered a MRI scan, and by the end of the trial, those results should be back as well.
What will happen next?
As discussed above, we will see you to do the next injection in your series and to followup on your injection results in roughly 6 weeks. We will give you this appointment
before we discharge you after the first treatment.
Our goal will be to find a combination of interventional pain procedures, medications,
physiotherapy, massage therapy, and psychological support which will get you back to
feeling and living better. As always, the doctors and staff at KOPI appreciate that you
have trusted us with your body and we will do everything possible to make your
procedure as smooth and anxiety free as possible. We want to help!
Thank you,
Dr. Greg Murphy
Dr. David Smith
Dr. John Cain
Dr. Joe Quigg
Dr. George Kolbe
and the rest of the KOPI Pain Team