Biceps Tendon Sheath Injection

Shoulder
Equipment & Medications

Equipment

14 MHz Linear Probe 25g 1.5″ Needle 5 cc Syringe (lidocaine) 3 cc Syringe (steroid mix) Procedure Tray

Medications

Lidocaine 1% — 5 cc Kenalog 40 mg/cc — 1 cc Ropivacaine 0.5% — 1 cc
Procedure Steps
1

Standard pre-procedure workup: consent, indications, contraindications, allergies, and baseline pain level.

2

Position patient recumbent with the forearm supinated (palm up), arm at side. The biceps tendon of interest should be on the far side from the ultrasound machine.

Patient positioning — forearm supinated
3

Scan the biceps tendon in the short axis (transverse). Assess both the extra-articular portion in the bicipital groove and the rotator interval. If fluid is present in the extra-articular sheath, inject there. Otherwise, inject at the rotator interval.

Extra-articular biceps tendon short axis
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Biceps tendon rotator interval
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4

Mark needle site and ideal probe location.

5

Prep patient with betadine or chlorhexidine × 3.

6

Place sterile drape and sterile probe cover.

7

Draw up medications as listed.

8

Create a skin wheal with the 25g needle and 1% lidocaine. Under ultrasound guidance, advance lidocaine deeper into the subcutaneous tissues.

Superficial lidocaine wheal technique
9

Once numb, leave the 25g needle in the soft tissues and disconnect the syringe for greater needle control.

10

Under ultrasound guidance, advance the 25g needle into the sheath surrounding the tendon.

Needle in biceps sheath
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11

Test-inject with 1% lidocaine. If there is no resistance and you see tendon sheath distention, exchange for the 3 cc syringe with steroid/ropivacaine and inject.

Test injection biceps sheath
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Biceps sheath distension
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12

Scan the sheath to document distention along its length.

Post-injection sheath
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Post-injection sheath additional view
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13

Remove needle, clean skin with alcohol, and place bandage.

14

Document pain level and provide patient with a pain log.

References

  1. Hashiuchi T, Sakurai G, Morimoto M, et al. Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg. 2011;20(7):1069–1073.
  2. Geannette C, Williams D, Berkowitz J, et al. Ultrasound-guided biceps tendon sheath injection: spectrum of preprocedure appearances. J Ultrasound Med. 2019;38(12):3267–3271.
  3. Slevin J, Joyce M, Galvin JW, et al. Ultrasound-guided biceps tendon sheath injections frequently extravasate into the glenohumeral joint. Arthroscopy. 2021;37(6):1711–1716.