Long head of biceps brachii tendon sheath injection (technique)
Citation, DOI & article data
- Proximal biceps brachii injection
- LHB injection
- LHB tendon sheath injection
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.
On this page:
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 focused 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.
References
- 1. Gofeld M, Hurdle M, Agur A. Biceps Tendon Sheath Injection: An Anatomical Conundrum. Pain Med. 2019;20(1):138-42. doi:10.1093/pm/pny051 - Pubmed
- 2. Park S, Choi Y, Kim H. Hypopigmentation and Subcutaneous Fat, Muscle Atrophy After Local Corticosteroid Injection. Korean J Anesthesiol. 2013;65(6 Suppl):S59-61. doi:10.4097/kjae.2013.65.6S.S59 - Pubmed
Related articles: Interventional procedures
- introduction
- procedure overview
- neck
- thyroid gland
- breast
- chest
-
hepatobiliary
- liver
- biliary system
- splenic interventions
- gastrointestinal
- urogenital
- bladder
- kidney
- prostate
- musculoskeletal
-
arthrogram
- MR arthrogram
- CT arthrogram
- anesthetic arthrogram
- bone biopsy (CT-guided)
- shoulder (disambiguation)
-
elbow
- common extensor origin microtenotomy
- common flexor origin microtenotomy
- distal biceps tendon sheath injection
- elbow joint injection
- median nerve injection
- ulnar nerve injection
-
hip
- hip joint injection
- common hamstrings origin microtenotomy
- gluteus minimus/ medius tendon calcific tendinopathy barbotage
- greater trochanteric bursa injection
- iliopsoas tendon bursa injection
- lateral femoral cutaneous nerve of the thigh injection
- piriformis injection
- quadratus femoris injection
-
knee
- common peroneal (fibular) nerve injection
- knee joint injection
- patella tendon microtenotomy
- quadriceps tendon microtenotomy
- tibial nerve injection
-
ankle
- achilles hydrodilation & microtenotomy
- ankle joint injection
- extensor tendon sheath injection
- flexor tendon sheath injection
- os trigonum injection
- peroneal tendon sheath injection
- subtalar joint injection
- tibial nerve injection
-
arthrogram
- spine
- vascular
Related articles: Imaging in practice
- imaging in practice
-
general radiography (adult)
- portable radiography
- chest radiography
- abdominal radiography
-
upper limb radiography
-
shoulder girdle radiography
- scapula series
-
shoulder series
- shoulder (AP view)
- shoulder (internal rotation view)
- shoulder (external rotation view)
- shoulder (superior-inferior axial view)
- shoulder (inferior-superior axial)
- shoulder (West Point view)
- shoulder (Velpeau view)
- shoulder (modified trauma axial view)
- shoulder (supine lateral view)
- shoulder (modified transthoracic supine lateral)
- shoulder (lateral scapula view)
- shoulder (AP glenoid view)
- shoulder (Garth view)
- shoulder (outlet view)
- shoulder (Stryker notch view)
- acromioclavicular joint series
-
clavicle series
- clavicle (AP view)
- clavicle (AP cephalic view)
- clavicle (oblique view)
- sternoclavicular joint series
- arm and forearm radiography
- wrist and hand radiography
- wrist series
- scaphoid series
- hand series
- thumb series
- fingers series
- rheumatology hands series
- bone age (radiograph)
-
shoulder girdle radiography
-
lower limb radiography
- pelvic girdle radiography
- thigh and leg radiography
- ankle and foot radiography
- skull radiography
-
paranasal sinus and facial bone radiography
- facial bones
- nasal bones
- zygomatic arches
- paranasal sinuses
- temporal bones
- dental radiography
- orthopantomography
- mandible
- mandible (PA view)
- mandible (PA axial view)
- mandible (AP axial view)
- mandible (oblique view)
- temporomandibular joints
- temporomandibular joint (AP axial view)
- temporomandibular joint (axiolateral view)
- temporomandibular joint (axiolateral oblique view)
-
spinal radiography
- cervical spine series
-
thoracic spine series
- thoracic spine (AP view)
- thoracic spine (lateral view)
- thoracic spine (oblique view)
- lumbar spine series
- sacrococcygeal radiography
- scoliosis radiography
-
pediatric radiography
- radiographic positioning terminology
- systematic radiographic technical evaluation (mnemonic)
- pediatric immobilization
- foreign body ingestion series (pediatric)
- foreign body inhalation series (pediatric)
- shunt series
- chest radiograph (pediatric)
- abdomen radiograph (pediatric)
- upper limb radiography (pediatric)
-
lower limb radiography (pediatric)
- pelvis radiograph (pediatric)
- femur series (pediatric)
- pediatric femur (AP view)
- pediatric femur (lateral view)
- leg length view
- knee series (pediatric)
- pediatric knee (AP view)
- pediatric knee (lateral view)
- tibia fibula series (pediatric)
- pediatric tibia fibula (AP view)
- pediatric tibia fibula (lateral view)
- pediatric tibia fibula (oblique view)
- ankle series (pediatric)
- pediatric ankle (AP view)
- pediatric ankle (mortise view)
- pediatric ankle (lateral view)
- foot series (pediatric)
- pediatric foot (DP view)
- pediatric foot (oblique view)
- pediatric foot (lateral view)
- skull radiography (pediatric)
- spine radiography (pediatric)
-
skeletal survey
-
skeletal survey (non-accidental injury)
- torso
- pediatric chest (AP erect view)
- pediatric chest (oblique ribs view)
- pediatric abdomen (AP supine view)
- pediatric spine (whole lateral view)
- upper limb (both sides)
- lower limb (both sides)
- pediatric femur (AP view)
- pediatric knee (lateral view)
- pediatric tibia fibula (AP view)
- pediatric ankle (lateral view)
- pediatric foot (DP view)
- torso
-
skeletal survey (non-accidental injury)
-
CT
- iodinated contrast media
- CT IV contrast media administration
-
CT protocol
- composite
- whole-body CT (protocol)
- CT Chest abdomen-pelvis (protocol)
- CT NCAP (neck, chest, abdomen and pelvis)
- head & neck
- chest
- abdomen and pelvis
- CT abdomen-pelvis (protocol)
- CT abdominal aorta
- CT adrenals (protocol)
- CT cholangiography (protocol)
- CT colonography (protocol)
- CT enteroclysis (protocol)
- CT enterography (protocol)
- CT gastrography (protocol)
- CT kidneys, ureters and bladder (protocol)
- CT urography (protocol)
- CT Renal mass (protocol)
- CT angiography of the splanchnic vessels (protocol)
- CT renal split bolus
- CT pancreas (protocol)
- liver
- composite
- barium studies
-
MRI
- cine imaging
-
brain
- screen protocol
- stereotaxis protocol
- tumor protocol
- stroke protocol
- infection protocol
- trauma protocol
- demyelination protocol
- epilepsy protocol
- neurodegenerative protocol
- trigeminal neuralgia protocol
- posterior fossa protocol
- temporal bone/IAM/CPA protocol
- pineal and tectal plate protocol
- pituitary gland protocol
- CSF flow
- angiographic protocols
- MRA
- circle of Willis (COW)
- carotid-vertebral system
- MRV
- MRA
- head and neck
- orbits protocol
- sinonasal tract protocol
- salivary glands protocol
- oropharynx and oral cavity protocol
- suprahyoid neck protocol
- infrahyoid neck protocol
- chest
- abdomen and pelvis
- abdomen
- liver and biliary tree
- liver protocol
- MRCP: cholangiopancreatography
- pancreas protocol
- elastography
- anus and rectum
- uterus and ovaries
- urological
- prostate cancer protocol
- bladder cancer protocol
- kidneys protocol
- musculoskeletal
-
ultrasound
- ultrasound signs
-
obstetric ultrasound
- other
- placenta
-
second trimester
- fetal biometry
- fetal morphology assessment
-
soft markers
- nuchal fold thickness
- ventriculomegaly
- absent nasal bone
- echogenic intracardiac focus
- choroid plexus cysts
- echogenic bowel
- aberrant right subclavian artery
- amnioreduction
- echogenic fetal bowel
- umbilical artery Doppler assessment
- chorionic villus sampling (CVS) and amniocentesis
- nuchal translucency
- failed early pregnancy
- subchorionic hematoma
- multiple gestations
- ectopic pregnancy
-
first trimester and early pregnancy
- gestational sac
- yolk sac
- embryo/fetus
- amnion
- chorion
- Beta-hCG levels
- gynecologic ultrasound
- vascular ultrasound
- carotids
- extremities
- mesenteric vessels
- other
- breast ultrasound
-
musculoskeletal ultrasound
- technique/artifacts
- ultrasound of arthropathies
- skin/soft tissue ultrasound
- lipoma
- parasitic infection
- other
- pediatric musculoskeletal ultrasound
- ankle/foot ultrasound
-
knee ultrasound
- Baker cyst (popliteal cyst)
- infrapatellar bursitis
- hip ultrasound
- hand ultrasound
- wrist ultrasound
- elbow ultrasound
- shoulder ultrasound
- liver ultrasound
- hyperechoic liver lesion
- sonographic halo sign
- ultrasound appearances of liver metastases
- periportal hyperechogenicity
- periportal hypoechogenicity
- generalized increase in hepatic echogenicity
- generalized reduced hepatic echogenicity
- coarsened hepatic echotexture
- starry sky appearance (ultrasound)
- normal hepatic vein Doppler
- hepatic arterial resistive index
- gallbladder ultrasound
- pancreatic ultrasound
- gastrointestinal ultrasound
- renal ultrasound
- bladder ultrasound
-
testicular and scrotal ultrasound
- other
- epididymis
- paratesticular lesions
- bilateral testicular lesion
-
unilateral testicular lesion
- testicular torsion
- orchitis
- testicular rupture
-
germ cell tumor of the testis
- testicular seminoma
-
non seminomatous germ cell tumors
- mixed germ cell tumor
- yolk sac tumor (endodermal sinus tumor)
- embryonal cell carcinoma
- choriocarcinoma
- testicular teratoma
- testicular epidermoid (teratoma with ectodermal elements only)
- burned out testis tumor
- sex cord / stromal tumors of the testis
- prostate ultrasound
- neck and thyroid ultrasound
- echocardiography
- speckle tracking echocardiography
- fetal echocardiography
- contrast-enhanced echocardiography
- epicardial echocardiography
- three dimensional (3D) echocardiography
- transesophageal echocardiography (TEE)
- transthoracic echocardiography (TTE)
- left ventricular systolic and diastolic function
- structure and morphology
- systolic function
- diastolic function
- right ventricular assessment
- right and left atria
- valvular structure and function
- mitral valve
- aortic valve
- pulmonic valve
- tricuspid valve
- hemodynamics
- pericardium
- cardiomyopathies
- congenital heart disease
- great vessels
- pediatric ultrasound
- ultrasound interventions
- ultrasound-guided biopsy
- ultrasound-guided percutaneous drainage
- ultrasound-guided musculoskeletal interventions
- joint injection
- nerve blocks
- ultrasound-guided intravenous cannulation
- contrast-enhanced ultrasound
- physics and imaging modes
- grey-scale (B-mode)
- motion mode (M-mode)
- color flow Doppler (CFD)
-
spectral Doppler
- pulsed wave Doppler (PWD)
- continuous wave Doppler (CWD)
- superb microvascular imaging (SMI)
- tissue Doppler imaging (TDI)
- nuclear medicine
-
radiation therapy
- external beam radiation therapy (EBRT)
- sealed source radiation therapy (brachytherapy)
- unsealed source radiation therapy
-
interventional
- procedure overview
- neck
- thyroid gland
- breast
- chest
- hepatobiliary
- splenic interventions
- gastrointestinal
- urogenital
- bladder
- kidney
- prostate
- musculoskeletal
-
arthrogram
- MR arthrogram
- CT arthrogram
- anesthetic arthrogram
- bone biopsy (CT-guided)
-
arthrogram
- upper limb
- lower limb
-
hip
- hip joint injection (technique)
- greater trochanteric bursa injection
- gluteus minimus/medius tendon calcific tendinopathy barbotage
- iliopsoas tendon bursa injection
- lateral cutaneous femoral nerve of the thigh injection
- piriformis injection
- common hamstrings origin injections
-
knee
- common peroneal (fibular) nerve injection
- knee joint injection
- patella tendon microtenotomy
- quadriceps tendon microtenotomy
- tibial nerve injection
-
ankle
- achilles hydrodilation & microtenotomy
- ankle joint injection
- extensor tendon sheath injection
- flexor tendon sheath injection
- os trigonum injection
- peroneal tendon sheath injection
- subtalar joint injection
- tibial nerve injection
-
foot
- calcaneocuboid joint injection
- metatarsophalangeal joint (MTPJ) injection
- naviculocuneiform joint injection
- plantar fascia microtenotomy
- subtalar joint injection
- talonavicular joint injection
- tarsometatarsal joint (TMTJ) injection
-
hip
- spine
- breast imaging
-
mammography
- breast screening
- breast imaging and the technologist
- forbidden (check) areas in mammography
-
mammography views
- craniocaudal view
- mediolateral oblique view
- additional (supplementary) views
- true lateral view
- lateromedial oblique view
- late mediolateral view
- step oblique views
- spot view
- double spot compression view
- magnification view
- exaggerated craniocaudal (axillary) view
- cleavage view
- tangential views
- caudocranial view
- bullseye CC view
- rolled CC view
- elevated craniocaudal projection
- caudal cranial projection
- 20° oblique projection
- inferomedial superolateral oblique projection
- Eklund technique
- normal breast imaging examples
-
mammography
- digital breast tomosynthesis
- breast ultrasound
- breast ductography
- breast MRI
- breast morphology
- breast intervention