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Biceps Tendon Sheath Injection

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Other Names

  • Biceps Tendon Sheath Injection
  • Long Head of the Biceps Brachii Tendon Injection


Anatomy illustration of the biceps brachii
  • This page refers to injection of the long head of the biceps brachii tendon (LHBBT)
    • This procedure should be performed with ultrasound guidance




  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
    • Septic Bursitis
    • History of Total Shoulder Arthroplasty
  • Relative
    • Can be treated with less invasive means
    • Tendon tear or rupture
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection


Biceps tendon in short axis with peritendinous fluid.


  • Sterile including chloraprep, chlorhexadine, iodine
  • Ultrasound with sterile probe cover
  • Gloves
  • Needle: typically 21-25 gauge, 1.5 inch
  • Syringe: 5-10 mL
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid
Biceps Tendon Sheath Injection in short axis.


  • Ultrasound evaluation
    • Identify the LHBBT in short axis
    • The patient is supine, shoulder slightly externally rotated, elbow extended with forearm supinated
    • Probe position is typically very proximal, just inferior to the coracoid process
    • Indentify the tendon in short axis within the bicipital groove
    • If an effusion is present, it is easily identified as a hypoecoic collection in the LHBBT sheath
    • It can be seen in short and long axis

Short Axis Technique

(a) Scheme and (b) ultrasound image of long head of biceps tendon sheath injection. The needle (arrowheads) is inserted with lateral, in-plane approach to place the tip within the tendon sheath (here already distended by some fluid; asterisks). Note that the underlying biceps tendon (arrows) has been carefully avoided. H, humerus.[1]
  • LHBBT is examined short axis to identify the area of greatest fluid around the tendon
  • Colour Doppler can be used to identify the anterior circumflex artery
  • Needle is inserted with an in-plane approach lateral to medial
  • Identify or create a window
    • If no fluid collection is present, use 5-10 cc anesthetic to create a window in the LHBBT
    • Remove first syringe with anesthetic while leaving needle in place
    • Note, If fluid collection is present, this can be used as the window
  • Attach second syringe with corticosteroid
    • Identify needle tip and confirm it is in window, then inject corticosteroid
    • It is important to avoid penetrating or injecting into the tendon

Long Axis Technique

  • Needs to be updated


  • No major restrictions in most cases
  • Can augment with ice, NSAIDS


  • Skin: Subcutaneus fat atrophy, skin atrophy, skin depigmentation
  • Painful local reaction
  • Infection
  • Hyperglycmia
  • Tendon, nerve or blood vessel injury
  • Tendon rupture
    • Frequency unknown
    • Using ultrasound guidance, the tendon should never be injected

See Also


  1. Messina, Carmelo, et al. "Ultrasound-guided interventional procedures around the shoulder." The British journal of radiology 89.1057 (2016): 20150372.
Created by:
Jesse Fodero on 10 July 2019 19:09:30
Last edited:
11 September 2022 06:27:45