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Ultrasound · Shoulder

Long Head of the Biceps Tendon Sheath Injection

shoulderbicepssheathtenosynovitis

Treats

  • Biceps tendon sheath inflammation
  • Diagnostic sheath injection

Contraindications

  • Active local skin infection at entry site (absolute)
  • Suspected septic tenosynovitis (absolute)
  • Known allergy to local anesthetic, steroid, or antiseptic prep
  • Therapeutic anticoagulation — review case-by-case
  • Uncontrolled diabetes (relative)
  • Recent biceps tendon rupture or high-grade tear (relative — particulate steroid increases re-rupture risk)

Pre-procedure checklist

  • Confirm patient identity (two identifiers)
  • Confirm procedure, side, and site
  • Review allergies and anticoagulation
  • Confirm informed consent
  • Pre-scan with Doppler to identify the AHC artery position in the groove
  • Time-out immediately before needle entry

Positioning

  • Patient seated; forearm supinated and resting on the lap or a table (palm up)
  • Slight external rotation of the shoulder brings the bicipital groove anterior and accessible
Positioning

Probe

  • High-frequency linear probe (6-13 MHz) (short footprint helpful)
Probe

Landmarking — find the view

  • Visual Cue: The "Bicipital Valley" — identify the deep bony groove between the greater and lesser tuberosities.
  • Center the round, hyperechoic biceps tendon within the groove.
  • Rotate 90° into long-axis to confirm the tendon is intact and not subluxed.
  • Doppler Survey: Identify the ascending branch of the anterior humeral circumflex artery (typically transverse across the groove, often visualized medial in the groove near the lesser tuberosity).

The correct ultrasound view

  • Round/oval tendon centered in groove; thin dark rim around it = sheath
The correct ultrasound view

Needle corridor

  • Lateral → medial path (from greater tuberosity side) into the thin dark rim around tendon — stop the tip in the sheath BEFORE reaching the medial groove wall where the AHC artery typically lies. Not intratendinous.
Needle corridor

Avoid

  • Ascending branch of the anterior humeral circumflex artery (Doppler before every entry — if it sits in the planned path, re-plan)
  • Intratendinous steroid

Steps

  1. 1Advance in-plane lateral-to-medial; inject a tiny test amount for circumferential 'target sign'; inject the planned volume once confirmed.
  2. 2STOP IMMEDIATELY if the patient reports electric, shooting, or paresthetic sensations.

Tips

  • If fluid collects above tendon or into SA space, you are in the wrong layer — readjust before steroid.
  • The biceps sheath communicates with the GH joint — anticipate some intra-articular steroid spread. Lower doses reduce systemic load and rupture risk.
  • Limit to ≤ 3 injections per year per tendon.

Resident pearls

  • Create a "test effusion" with local to confirm circumferential spread around the tendon.
  • Always Doppler before entry — the AHC artery position varies; if it sits in the planned path, re-plan.
  • Total injectate (anesthetic + steroid) ≤ 3 mL to avoid overfilling the sheath and retrograde GH joint tracking.

Supplies

  • 5 mL Syringe
  • 25G 1.5" Needle
  • 18G Drawing Needle
  • 1% Lidocaine (1-2 mL)
  • Triamcinolone 20-40 mg OR Dexamethasone 4-8 mg
  • Alcohol Swabs (vial tops)
  • Betadine/Chloraprep
  • Sterile Gloves
  • Sterile 4x4 Gauze Pads
  • Sterile Towels & Drapes
  • Adhesive Bandage (Band-Aid)
  • Washcloth/Towel (gel cleanup)
  • Needle Disposal Safety Cap
  • Sterile probe cover & gel

Post-procedure

  • Apply a clean dressing; remove after 24 hours.
  • Local anesthetic relief for 1-4 hours; steroid begins 24-72 hours.
  • Steroid 'flare' in 2–10% — manage with ice and acetaminophen.
  • Rest the shoulder 24-48 hours; avoid heavy lifting for 1 week.
  • Return immediately for: spreading redness, swelling, fever, or disproportionate pain.
  • Diabetics: expect 50-100 mg/dL glucose rise for 3-5 days.
  • Maximum 3 injections per tendon per year.