Bicipital Tendon Injection Technique

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.

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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.