Shoulder pain, particularly from conditions such as rotator cuff tendinopathy, frozen shoulder and arthritis, is a prevalent clinical issue. SSNB blocks approximately 70% of the sensory input to the shoulder joint and is well-established in pain management [2,3].

While various treatments exist, suprascapular nerve block (SSNB) combined with intra-articular steroid injection has proven to be an effective management approach. SSNB has traditionally been performed using ultrasound guidance; however, its availability is limited in many low-resource settings. Meier’s anatomical landmark technique for SSNB provides a reliable alternative in the absence of ultrasound. This study evaluates the clinical outcomes of SSNB with intra-articular steroid injection for shoulder pain management at Zonal Hospital, Dharamshala, where ultrasound is unavailable.

MATERIALS AND METHODS

This prospective case series was conducted at Zonal Hospital, Dharamshala, over a three-month period from January 2025 to March 2025. The study included patients presenting with chronic shoulder pain attributed to conditions such as rotator cuff pathology, frozen shoulder and adhesive capsulitis. All patients selected had persistent symptoms despite conservative management, including physical therapy and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Participants underwent suprascapular nerve block (SSNB) combined with intra-articular steroid injection as part of their treatment protocol.               

Inclusion criteria comprised adults aged between 18 and 70 years who had chronic shoulder pain that remained unresponsive to conservative therapy and who had no contraindications to local anesthetics or corticosteroids. Exclusion criteria included patients with active infections, known allergic reactions to anesthetics or steroids and those with significant comorbidities that would contraindicate the procedure, such as active rheumatoid arthritis or the presence of a local infection at the proposed injection site.

Procedure

SSNB was performed using Meier’s technique, which involves palpating the coracoid process and the spine of the scapula to locate the suprascapular notch [1]. 22G 5cm needle inserted 2 cm above scapular spine, lateral to medial, targeting the suprascapular notch. 

Injection-gauge needle was used to inject. 25% bupivacaine and 40 mg triamcinolone at the suprascapular notch. Intra-articular steroid injection (40 mg triamcinolone) was administered if joint pathology was suspected (Figure 1).

Figure 1: Needle entry point for Meier’s technique, (Anatomical landmarks for Meier’s SSNB approach)

Monitoring

Following the procedure, vital signs including heart rate, blood pressure, respiratory rate and oxygen saturation were monitored continuously for 30 minutes to ensure immediate post-injection safety. Pain intensity was evaluated using the Visual Analog Scale (VAS), recorded both pre-procedure and again four weeks after the intervention to assess changes over time. Outcome measures for the study included two key parameters: pain relief and functional improvement. Pain relief was quantified using the VAS, comparing scores before and after the procedure. Functional improvement was assessed using the Shoulder Pain and Disability Index (SPADI), a validated instrument designed to measure both pain and functional impairment in patients with shoulder disorders.

A total of 30 patients (18 males, 12 females) with a mean age of 54.6 years (range 40-70) were included. The majority of patients (70%) had rotator cuff tendinopathy and 30% had frozen shoulder.

Pain Relief

The mean VAS score before the procedure was 8.2 (range 7-10). At follow-up (4-6 weeks), the mean VAS score had reduced to 3.1 (range 0-6), indicating significant pain relief (p<0.05).

Functional Improvement

The mean pre-treatment SPADI score was 72.4 (range 60-85). Post-procedure, the mean SPADI score decreased to 40.7 (range 20-60), reflecting functional improvement in 85% of the patients (p<0.05).

Patient Satisfaction

90% of patients reported being satisfied or very satisfied with the outcome of the procedure. No significant complications were reported.

SSNB using Meier’s technique provides an effective alternative for pain management in settings where ultrasound is unavailable [4]. The technique relies on palpating anatomical landmarks, making it feasible even in resource-limited environments like Zonal Hospital Dharamshala. The combined use of SSNB and intra-articular steroid injections provided significant pain relief and functional improvement in our cohort. The results are consistent with previous studies demonstrating the efficacy of SSNB in managing shoulder pain, even without ultrasound guidance. High satisfaction reinforces its acceptability and feasibility among rural patients [5].

The study also emphasizes the role of intra-articular steroid injections in patients with underlying joint pathology,  such  as  rotator  cuff  tendinopathy  and frozen shoulder. The success of this technique is likely due to its ability to address both the nerve-mediated pain and intra-articular inflammation simultaneously.

While the study’s small sample size and retrospective nature limit the generalizability of the findings, the results suggest that SSNB using Meier’s technique is a safe, effective and feasible approach to managing shoulder pain in low-resource settings.

SSNB with Meier’s technique, combined with intra-articular steroid injection, is a viable and effective management strategy for shoulder pain in resource-limited settings. It offers significant pain relief and functional improvement without the need for expensive or specialized equipment like ultrasound. Further prospective studies with larger sample sizes are needed to validate these findings.

1. Meier, T. and D. Rempel. "Suprascapular Nerve Entrapment and Pain: Anatomy and Technique for Block." Clinical Orthopaedics and Related Research, vol. 466, no. 4, 2008, pp. 940-946.

2. Dangoisse, M.J., P. Herve and L. Doursounian. "Suprascapular Nerve Block: Anatomy and Technique." Regional Anesthesia and Pain Medicine, vol. 19, no. 5, 1994, pp. 361-364.

3. Harmon, D. and C. Hearty. "Ultrasound-Guided Suprascapular Nerve Block Technique." Pain Physician, vol. 10, no. 6, 2007, pp. 743-746.

4. Shah, N. and J. Lewis. "Shoulder Pain: Assessment, Diagnosis and Management in Primary Care." BMJ, vol. 371, 2020, Article ID m3024.

5. Lafosse, L., et al. "Suprascapular Nerve Release: Indications and Surgical Technique." Arthroscopy, vol. 23, no. 7, 2007, Article ID e29-e33.