Long head of biceps brachii tendon sheath injection (technique)

Long head of biceps brachii (LHB) tendon sheath injections under ultrasound guidance ensure accurate delivery of injectate, which is important as these injections are often performed for diagnostic purposes.   

Indications

• pain
• diagnostic injection
• alternative access to the glenohumeral joint (shoulder) ¹

Contraindications

Absolute

• anaphylaxis to contrast/injectates
• active local/ systemic infection 

Relative

• bleeding diathesis
• recent injection with steroid in same/ other body parts
• long head of biceps and/ or rotator cuff tendon tears
• unable to remain still for the procedure
• young age

Procedure

The general principles of guided injections are to:

• cannulate the structure under image guidance
• administer injectate under visualization, usually a corticosteroid and a small amount of longer-acting local anesthetic, and avoiding intra-tendinous injection

Pre-procedural evaluation

Relevant imaging should be reviewed, and details of the patient confirmed.  The patient should have an opportunity to discuss the risks and benefits and consent obtained. A focussed pre-procedure ultrasound is usually performed.  

Risks include

• infection
• bleeding
• allergy 
• focal fat necrosis/ skin discolouration at injection site
• complete tendon tear

Equipment

• ultrasound machine, sterile probe cover and a skin marker
• skin cleaning product
• sterile drape
• sterile field and tray for sharps
• syringe selection i.e. 5mL and 3mL
• larger bore drawing up needle
• needle to administer local anesthetic i.e. 30 or 25-gauge needle
• needle to cannulate the tendon sheath i.e. 25 or 27-gauge needle
• injectants i.e. local anesthetics, iodinated contrast, corticosteroid preparation
• sterile gauze
• adhesive dressing

Syringe selection

A suggested syringe and injectate selection for an ultrasound-guided LHB tendon sheath injection

• 5 mL syringe: 5 mL of local anesthetic i.e. 1% lidocaine
• 3 mL syringe: 40mg triamcinolone acetonide (40 mg/1 mL) and 2 mL 0.5% ropivacaine

Needle selection

Smaller gauge needles can be less painful but are less stiff and can bend when trying to cannulate a structure. Ensure the needle length is long enough to reach the target point in the sheath.

• LHB tendon sheath: 25 or 27-gauge 40mm needles 
• LHB tendon sheath: 25 gauge Quincke needle (larger patients)

Technique

Ultrasound

• check for allergies and if on blood thinners
• consent
• optimize patient positioning by lying them flat and supine or with minimal upright bed angulation with the target arm straight, by their side with the hand supinated, targeting a lateral access
• identify the LHB tendon in the transverse plane; perpendicular to the long axis, optimize imaging and mark a lateral skin entry point
• clean skin and draw up appropriate medications
• consider local anesthesia along the proposed needle path
• under ultrasound guidance using lateral approach, insert the needle in-plane with the probe into the lateral and inferior aspect of the LHB tendon sheath
• the needle tip position can be checked with a small amount of injected local anesthetic, which should flow freely
• administer steroid containing injectate under direct visualization, avoiding intra-tendinous injection
• removed needle and apply dressing/ band-aid as required
• pain diary given if a diagnostic injection

Complications

The most serious complication is infection. Steroid containing injections should be postponed if there are signs and/or symptoms of local and/ or systemic infection.  Fat necrosis causing skin dimpling and skin discolouration can occur due to steroid leaking into the surrounding soft tissues ².