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Biceps Tendon Sheath Injection Other Names Biceps Tendon Sheath Injection Long Head of the Biceps Brachii Tendon Injection Background This page refers to injection of the long head of the biceps brachii tendon (LHBBT) This procedure should be performed with ultrasound guidance Key Points Use a high frequency linear transducer Most easily identified in short axis in the bicipital groove between greater and lesser tuberosities The anterior circumflex artery lies lateral to the tendon within the sheath Anatomy of the Bicipital Groove Biceps Brachii Long head originates on the supraglenoid tubercle and glenoid labrum Short head originates on coracoid process Both coalesce into the main muscle belly Insert on the radial tuberosity Long head Sits in the bicipital groove of the humerus This is the target for the procedure Palpation vs Ultrasound Guidance The biceps tendon sheath can not be reliably injected using palpation guidance One study found an accuracy of only 26.7% using palpation guidance [2] Ultrasound should be considered mandatory to perform this procedure Indications Contraindications Absolute Anaphylaxis to injectates Overlying cellulitis, skin lesion or systemic infection Septic Bursitis History of Total Shoulder Arthroplasty Relative Can be treated with less invasive means Tendon tear or rupture Hyperglycemia or poorly controlled diabetes Lack of symptom improvement with previous injection Procedure Equipment Sterile including chloraprep, chlorhexadine, iodine Ultrasound with sterile probe cover Gloves Needle: typically 21-25 gauge, 1.5 inch Syringe: 5-10 mL Gauze Ethyl Chloride Bandage Injectate Local anesthetic Corticosteroid/ injectate Ultrasound Findings Finding your target Identify the LHBBT in short axis The patient is supine, shoulder slightly externally rotated, elbow extended with forearm supinated Probe position is typically very proximal, just inferior to the coracoid process Indentify the tendon in short axis within the bicipital groove If a tendon sheath effusion is present, it is easily identified as a hypoecoic collection in the LHBBT sheath The effusion typically forms an isoechoic ring around the biceps tendon in short axis (called the "ring sign") It can be seen in short and long axis Other findings The transverse humeral ligament can be seen as a thin, hyperechoic linear structure just superficial to the tendon Localized tenosynivitis vs effusion from the glenohumeral joint can be made Patients with localized tenosynovitis will experience localized pain from sonopalpation A glenohumeral effusion extending in the tendon sheath is typically not painful along the biceps tendon Ultrasound Guided: Short Axis Technique Authors preferred technique Patient position The patient is supine, arm is externally rotated with forearm supinated Transducer position Short axis to biceps tendon LHBBT is examined short axis to identify the area of greatest fluid around the tendon Colour Doppler can be used to identify the anterior circumflex artery Needle orientation In plane Lateral to medial Identify or create a window If no fluid collection is present, use 5-10 cc anesthetic to create a window in the LHBBT Remove first syringe with anesthetic while leaving needle in place Note, If fluid collection is present, this can be used as the window Attach second syringe with corticosteroid Identify needle tip and confirm it is in window, then inject corticosteroid It is important to avoid penetrating or injecting into the tendon Pearls and Pitfalls In larger patients, a longer needle may be required Try to avoid fenestrating the tendon Identify the anterior circumflex artery, avoid during procedure Ultrasound in long and short axis to confirm spread of injectate in correct tissue space Ultrasound Guidance: Long Axis Technique Patient position The patient is supine, arm is externally rotated with forearm supinated Transducer Position Sagittal plane Long axis of biceps tendon Needle orientation In plane Proximal to distal Pearls and Pitfalls Can switch to short axis to confirm needle placement within the tendon sheath Aftercare No major restrictions in most cases Can augment with ice, NSAIDS Complications Skin: Subcutaneus fat atrophy, skin atrophy, skin depigmentation Painful local reaction Infection Hyperglycmia Tendon, nerve or blood vessel injury Tendon rupture Frequency unknown Using ultrasound guidance, the tendon should never be injected See Also References ↑ van Deurzen, Derek FP, et al

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