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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

Key Points

  • Use a high frequency linear transducer
  • Most easily identified in short axis in the bicipital groove between greater and lesser tuberosities
  • The anterior circumflex artery lies lateral to the tendon within the sheath


Palpation vs Ultrasound Guidance

  • The biceps tendon sheath can not be reliably injected using palpation guidance
    • One study found an accuracy of only 26.7% using palpation guidance[1]
  • Ultrasound should be considered mandatory to perform this procedure
    • Hashiuchi et al found ultrasound guidance improves accuracy to 86.7%[1]
    • Ultrasound guidance has been shown to result in a statistically significantly higher degree of pain relief[2]



  • 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.

Biceps Tendon Sheath Injection in short axis.
Effusion surrounding the biceps tendon sheath in short and long axis. On the left, the so-called "ring" or "halo" sign.[3]
Probe position for short axis (A) and long axis (B) approaches.[4]
(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.[5]


  • 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/ injectate

Ultrasound Findings

  • Finding your target
    • 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 a tendon sheath effusion is present, it is easily identified as a hypoecoic collection in the LHBBT sheath
    • The effusion typically forms an isoechoic ring around the biceps tendon in short axis (called the "ring sign")
    • It can be seen in short and long axis
  • Other findings
    • The transverse humeral ligament can be seen as a thin, hyperechoic linear structure just superficial to the tendon
    • Localized tenosynivitis vs effusion from the glenohumeral joint can be made
    • Patients with localized tenosynovitis will experience localized pain from sonopalpation
    • A glenohumeral effusion extending in the tendon sheath is typically not painful along the biceps tendon

Ultrasound Guided: Short Axis Technique

  • Authors preferred technique
  • Patient position
    • The patient is supine, arm is externally rotated with forearm supinated
  • Transducer position
    • Short axis to biceps tendon
    • 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 orientation
    • In plane
    • 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
  • Pearls and Pitfalls
    • In larger patients, a longer needle may be required
    • Try to avoid fenestrating the tendon
    • Identify the anterior circumflex artery, avoid during procedure
    • Ultrasound in long and short axis to confirm spread of injectate in correct tissue space

Ultrasound Guidance: Long Axis Technique

  • Patient position
    • The patient is supine, arm is externally rotated with forearm supinated
  • Transducer Position
    • Sagittal plane
    • Long axis of biceps tendon
  • Needle orientation
    • In plane
    • Proximal to distal
  • Pearls and Pitfalls
    • Can switch to short axis to confirm needle placement within the tendon sheath


  • 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. 1.0 1.1 Hashiuchi, Tomohisa, et al. "Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial." Journal of shoulder and elbow surgery 20.7 (2011): 1069-1073.
  2. Zhang, Jingwei, Nabil Ebraheim, and Gregory E. Lause. "Ultrasound-guided injection for the biceps brachii tendinitis: results and experience." Ultrasound in medicine & biology 37.5 (2011): 729-733.
  3. Manske, Robert C., et al. "Long Head of the Biceps Tendon (LHBT)." International Journal of Sports Physical Therapy 17.7 (2022): 1205-1207.
  4. Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  5. 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:
19 April 2023 14:22:32