Long head of biceps brachii tendon sheath injection (technique)

Long head of biceps brachii (LHB) tendon sheath injections under ultrasound-guidance ensures 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

Contra-indications

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/ band aid

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.