Bicipital Tendon Injection

Biceps (bicipital) tendinitis is an inflammation of the long head of the biceps tendon as it passes through the bicipital groove of the anterior humerus (see the image below).[1, 2]

Bicipital tendon.

Repetitive lifting and, to a lesser extent, overhead reaching can lead to inflammation, microtearing, and, if the condition goes untreated, degenerative changes. Patients with bicipital tendinitis typically report anterior shoulder or humeral pain aggravated by lifting or overhead reaching. The patient often takes one finger and points directly to the bicipital groove when describing the pain. Patients may not be able to flex at the elbow against resistance because of the pain of active tendinitis.

Anesthetic block may be necessary to distinguish the pain from the referred pain of rotator cuff pathology. The diagnosis is mostly clinical and specialized radiographic testing is rarely necessary.

The goals of therapy for bicipital tendinitis are as follows[1] :

• Reduce tendon inflammation and swelling
• Strengthen the biceps muscle and tendon to prevent repeat inflammation
• Prevent  rupture

Local corticosteroid injection may be used to relieve symptoms in patients with symptoms that persist for more than 4 weeks despite conservative treatment. Long-term outcome, however, is much the same for patients who undergo joint injection to treat bicipital tendinitis as for those who do not.

Physical therapy is helpful for most of these patients.

Bicipital groove injection, the most precise anatomic injection, is recommended in patients younger than 50 years.

The risk of tendon rupture is greater in patients aged 50 years and older. A subacromial injection is preferred in this population because it avoids direct needle penetration of the tendon.

Corticosteroid joint injection can speed up recovery from bicipital tendinitis in high-performance athletes, but this is a controversial indication.

Few absolute contraindications exist for joint or soft-tissue aspirations and injections. The procedures should probably be avoided if the overlying skin or subcutaneous tissues are infected or if bacteremia is suspected. The presence of a significant bleeding disorder, diathesis, or severe thrombocytopenia may also preclude joint aspiration.

Aspiration of a joint with a prosthesis carries a particularly high risk of infection and is often best left to surgeons using full aseptic techniques. If infection is suspected as the underlying cause of the musculoskeletal problem, corticosteroids must not be injected, because they may exacerbate the infection.

Warfarin anticoagulation with international normalization ratio (INR) values in the therapeutic range is not a contraindication for joint or soft-tissue aspiration or injection.

Aspiration or injection of soft tissues may be performed as an outpatient procedure and does not require specialized equipment.[3]  The following necessary equipment is readily available:

• Needle, 25-27 gauge
• Syringe, 3-5 mL
• Triamcinolone acetonide injection, 40-80 mg
• Lidocaine 1% without epinephrine, 0.5-1 mL

Anesthesia

Most experienced physicians prefer to use topical ethyl chloride or no anesthetic at all.

Positioning

Have the patient sit with hands in the lap. Ask the patient to relax the shoulder and neck muscles. Locate and mark the humeral head and the lateral edge of the acromion. The point of entry is directly over the bicipital groove, located approximately 2.5-3.0 cm (~1.0-1.25 in.) caudal to the anterolateral edge of the acromion. The groove is palpable when the arm is passively rotated internally and externally as the examiner's fingers are over the anterolateral humeral head.

The success of treatment depends upon effective control of inflammation of the biceps tendon. Sterile precautions are required during the procedure.

Spray ethyl chloride on the skin. Position a 1.5-in. (~3.8-cm) 25-gauge needle perpendicular to the skin. Prepare to inject the mix of local anesthetic and corticosteroid.

Insert the needle up to 0.5-0.75 in. (~1.25-1.9 cm) to either bony prominence or 0.75-1.0 in. (~1.9-2.5 cm) to the bottom of the groove (see the image below).[4]  Keep the bevel of the needle parallel to the fibers of the tendon during the entire procedure.

Injection in bicipital groove.

Ultrasound guidance may be helpful.[5, 6, 7, 8, 9]  Fluoroscopic guidance of injection into the supraglenoid tubercle has been described.[10]  In a 10-year retrospective review comparing ultrasound-guided (n = 53) with fluoroscopy-guided (n = 50) biceps tendon sheath injection, Petscavage-Thomas et al found the former to be more accurate, with similar pain relief and complication rates.[11]

Advance the needle until the "rubbery" firm resistance of the tendon or the hard resistance of the humerus is felt. Then withdraw the needle 0.25 in. (0.6 cm) and inject the corticosteroid.[4]  Inject only under light pressure. Resistance when injecting suggests either intratendinous injection (which can lead to tendon rupture) or periosteal injection.

Deliver the following aftercare instructions to the patient:

• Rest for 1-2 days, avoiding all lifting
• Apply ice (15 minutes every 4-6 hours) to the lateral deltoid, and take acetaminophen (1000 mg every 12 hours) for soreness, which is often slightly worse before improvement is appreciated
• Because the long head of the biceps tendon is located under the acromion, protect the tendon for 30 days by avoiding or at least limiting lifting (eg, by lifting only low weights and holding them close to the body) and overhead reaching or positioning
• Delay regular activities, work, and sports until the lost tone has fully recovered

If overall improvement is less than 50% at 8-12 weeks, repeat the injection.

Orthopedic consultation should be considered in patients with symptoms that have persisted for more than 3 months despite the above measures. Surgery is rarely required for bicipital tendinitis.

Surprisingly few complications arise as results of injection procedures. Patients who have severe immunodeficiencies or implants may be at greater risk for complications.

The most significant issue is the risk of infection. Care must always be taken to use sterile "no-touch" techniques. Corticosteroids are contraindicated in patients with septic arthritis. The estimated risk of septic arthritis after a corticosteroid injection is on the order of 1 per 15,000 procedures.[12]

The best-described complication is tendon rupture after corticosteroid injections for tendinitis. The risk of this complication can be minimized by avoiding injection into the tendon itself. No therapeutic agent should be injected against any unexpected resistance.

Skin atrophy is a frequent complication of superficial infiltrations and olecranon bursa injections. The condition is characterized by cigarette-paper – like skin, recurrent ecchymosis, and chronic pressure pain. Postinjection atrophy is more likely to develop in elderly individuals.

Corticosteroid-induced osteoporosis can occur after repeated injections in joints and soft tissues.

Occasionally, nerve damage can result from a misplaced injection (eg, median nerve atrophy following attempted injections for a carpal tunnel syndrome). Other complications can also arise from misplaced injections.

Transient increase in pain is seen in 20-40% of patients.[12]  Repeated corticosteroid infiltrations may result in chronic pain.