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Biceps Tendon Sheath Injection—In-Plane Approach
Biceps Tendon Sheath Injection—In-Plane Approach: Ultrasound Guidance Stephen C. Johnson, Melinda S. Loveless, and Michael B. Furman The biceps muscle has two heads, a long head and a short head, which attach to the scapula via individual tendons. Pathology commonly affects the long head, which is generally referred to as the biceps tendon. The long head of the biceps originates from the supraglenoid tubercle, labrum, and the joint capsule. It then passes through the triangular space between the tendons of the subscapularis and supraspinatus muscles called the rotator cuff interval. Here, the biceps tendon is stabilized by the coracohumeral ligament and superior glenohumeral ligament. As the biceps tendon travels distally it remains in a synovial sheath, shared with the anterior circumflex artery, for approximately 3–4 cm. As the biceps tendon reaches the proximal humerus, it courses through the intertubercular groove (also called the bicipital groove) between the greater tuberosity (lateral) and the lesser tuberosity (medial). At this position, it is stabilized in the bicipital groove by the overlying transverse humeral ligament. Bicipital tenosynovitis is most often secondary to impingement beneath the coracoacromial arch near the bicipital groove but may also occur secondary to instability. Fluid within the sheath is considered abnormal and may occur with localized tenosynovitis. However, the origin of the biceps tendon is intraarticular, thus effusions as a result of intraarticular pathology, such as glenohumeral osteoarthritis or rotator cuff tear, may leak into the biceps tendon sheath. Biceps tendon sheath injections can be considered for patients with anterior shoulder pain that localizes to the biceps tendon region with accompanying ultrasound findings of tenosynovitis or effusion. This chapter will describe an in-plane technique, short axis to the biceps tendon at the level of the bicipital groove, with out-of-plane confirmation. Safety considerations will also be highlighted, including the use of Doppler imaging to avoid anterior circumflex artery injection.
Note: Please see pages ii and iii for a list of anatomic terms/abbreviations used throughout this book.
CHAPTER
34F
Chapter 34F Biceps Tendon Sheath Injection—In-Plane Approach: Ultrasound Guidance
In-Plane Technique (Fig. 34F.1) Patient is positioned supine with arm in neutral position with palm up. Patient may also be seated with forearm supinated and elbow at 90 degrees of flexion. n Ultrasound image is on the opposite side of the interventionalist and in line with the transducer (see Fig. 34F.1A and Chapter 4). n Begin by placing the transducer short axis to the biceps tendon at the bicipital groove (axial plane). (Fig. 34F.1D). n An alternative long-axis (sagittal) approach may also be used by positioning the transducer long axis to the biceps tendon. The short-axis approach is preferred. n Identify the biceps tendon within its sheath beneath the transverse humeral ligament, in the intertubercular (bicipital) groove between the greater and lesser tuberosities (Fig. 34F.1A,B). n Toggle the transducer to minimize anisotropy and optimize tendon localization (see Chapter 4). n With the transducer short axis to the biceps tendon, insert the needle from lateral to medial toward biceps tendon sheath. n While visualizing the needle tip in plane, advance through the transverse humeral ligament and deep to the tendon sheath but superficial to the tendon (Fig. 34F.1A,B). n If the needle is superficial to the transverse humeral ligament it may be in the subacromial, subdeltoid bursa. n n
A
VII
Fig. 34F.1. A, Room and interventionalist setup for injection.
570
In-Plane Technique
Multiplanar view
B
Multiplanar view
C
Safety view
anterior circumflex artery
D
Fig. 34F.1, cont’d B, Ultrasound image of needle placement within the biceps tendon sheath, deep to the transverse humeral ligament, in the bicipital groove formed by the greater and lesser tuberosities. C, Drawing of relevant structures. Needle is green. Transverse humeral ligament is in orange. Biceps tendon sheath in blue. Red circle is the anterior circumflex humeral artery. D, Skeleton showing proper placement of ultrasound transducer.
In-Plane Technique Safety Considerations Use Doppler imaging to avoid vascular injection into the anterior circumflex artery, which lies lateral to the biceps tendon. n Avoid injection of the tendon itself—be sure to only inject the surrounding sheath—except in certain cases when injecting biologics. n
VII 571
Chapter 34F Biceps Tendon Sheath Injection—In-Plane Approach: Ultrasound Guidance
Out-of-Plane Confirmation (Fig. 34F.2) After placement deep to the biceps tendon sheath, rotate the transducer 90 degrees to an out-of-plane view to reconfirm that the needle tip is deep to the tendon sheath and superficial to this long-axis view of the biceps tendon (Figs. 34F.2A to C).
n
Multiplanar view
A
Multiplanar view
B
Safety view
C
Fig. 34F.2. A, Ultrasound image of out-of-plane needle placement in the dorsal aspect of the biceps tendon sheath. B, Drawing of relevant structures. Needle is green. Biceps tendon sheath in yellow. In this image, some of the injectate is also visualized in the subacromial, subdeltoid bursa superficial to the tendon sheath (black arrow). C, Skeleton showing proper placement of ultrasound transducer for out-of-plane confirmation.
Out-of-Plane Technique Safety Considerations Avoid injection of the biceps tendon. Spread of injectate should be visualized circumferentially around the tendon and within the sheath. n
VII
n
572
Optimal Images
Optimal Images (Fig. 34F.3A,B)
Optimal
A
Optimal
B Fig. 34F.3. A, Optimal needle placement within the biceps tendon sheath using an in-plane, short-axis approach. B, Optimal needle placement. Injectate is seen filling the biceps tendon sheath causing the transverse humeral ligament to distend.
VII 573
Chapter 34F Biceps Tendon Sheath Injection—In-Plane Approach: Ultrasound Guidance
Suboptimal Images (Fig. 34F.4 and Fig. 34F.5)
Suboptimal
A
Optimal
B Fig. 34F.4. A, Suboptimal needle placement with the needle superficial to the biceps tendon sheath. B, The needle is then advanced to an optimal location deep to the transverse humeral ligament and within the biceps tendon sheath.
VII
Suboptimal
Fig. 34F.5. Suboptimal needle placement using the alternative, long-axis approach with the needle tip superficial to the biceps tendon sheath within the subacromial, subdeltoid bursa. Injectate is seen filling the bursa and not the tendon sheath. The needle tip should be advanced slightly until within the sheath.
Suggested Readings Jacobson J. Fundamentals of Musculoskeletal Ultrasound. Philadelphia, PA: Saunders; 2007. Patton WC, McClusky GM III. Biceps tendinitis and subluxation. Clin Sports Med. 2001;20(3):505–529.
574
Spinner DA, Kirschner JS, Herrera JE, eds. Atlas of Ultrasound Guided Musculoskeletal Injections. New York, NY: Springer; 2014.
Note: Please see pages ii and iii for a list of anatomic terms/abbreviations used throughout this book.
CHAPTER
34F
Chapter 34F Biceps Tendon Sheath Injection—In-Plane Approach: Ultrasound Guidance
In-Plane Technique (Fig. 34F.1) Patient is positioned supine with arm in neutral position with palm up. Patient may also be seated with forearm supinated and elbow at 90 degrees of flexion. n Ultrasound image is on the opposite side of the interventionalist and in line with the transducer (see Fig. 34F.1A and Chapter 4). n Begin by placing the transducer short axis to the biceps tendon at the bicipital groove (axial plane). (Fig. 34F.1D). n An alternative long-axis (sagittal) approach may also be used by positioning the transducer long axis to the biceps tendon. The short-axis approach is preferred. n Identify the biceps tendon within its sheath beneath the transverse humeral ligament, in the intertubercular (bicipital) groove between the greater and lesser tuberosities (Fig. 34F.1A,B). n Toggle the transducer to minimize anisotropy and optimize tendon localization (see Chapter 4). n With the transducer short axis to the biceps tendon, insert the needle from lateral to medial toward biceps tendon sheath. n While visualizing the needle tip in plane, advance through the transverse humeral ligament and deep to the tendon sheath but superficial to the tendon (Fig. 34F.1A,B). n If the needle is superficial to the transverse humeral ligament it may be in the subacromial, subdeltoid bursa. n n
A
VII
Fig. 34F.1. A, Room and interventionalist setup for injection.
570
In-Plane Technique
Multiplanar view
B
Multiplanar view
C
Safety view
anterior circumflex artery
D
Fig. 34F.1, cont’d B, Ultrasound image of needle placement within the biceps tendon sheath, deep to the transverse humeral ligament, in the bicipital groove formed by the greater and lesser tuberosities. C, Drawing of relevant structures. Needle is green. Transverse humeral ligament is in orange. Biceps tendon sheath in blue. Red circle is the anterior circumflex humeral artery. D, Skeleton showing proper placement of ultrasound transducer.
In-Plane Technique Safety Considerations Use Doppler imaging to avoid vascular injection into the anterior circumflex artery, which lies lateral to the biceps tendon. n Avoid injection of the tendon itself—be sure to only inject the surrounding sheath—except in certain cases when injecting biologics. n
VII 571
Chapter 34F Biceps Tendon Sheath Injection—In-Plane Approach: Ultrasound Guidance
Out-of-Plane Confirmation (Fig. 34F.2) After placement deep to the biceps tendon sheath, rotate the transducer 90 degrees to an out-of-plane view to reconfirm that the needle tip is deep to the tendon sheath and superficial to this long-axis view of the biceps tendon (Figs. 34F.2A to C).
n
Multiplanar view
A
Multiplanar view
B
Safety view
C
Fig. 34F.2. A, Ultrasound image of out-of-plane needle placement in the dorsal aspect of the biceps tendon sheath. B, Drawing of relevant structures. Needle is green. Biceps tendon sheath in yellow. In this image, some of the injectate is also visualized in the subacromial, subdeltoid bursa superficial to the tendon sheath (black arrow). C, Skeleton showing proper placement of ultrasound transducer for out-of-plane confirmation.
Out-of-Plane Technique Safety Considerations Avoid injection of the biceps tendon. Spread of injectate should be visualized circumferentially around the tendon and within the sheath. n
VII
n
572
Optimal Images
Optimal Images (Fig. 34F.3A,B)
Optimal
A
Optimal
B Fig. 34F.3. A, Optimal needle placement within the biceps tendon sheath using an in-plane, short-axis approach. B, Optimal needle placement. Injectate is seen filling the biceps tendon sheath causing the transverse humeral ligament to distend.
VII 573
Chapter 34F Biceps Tendon Sheath Injection—In-Plane Approach: Ultrasound Guidance
Suboptimal Images (Fig. 34F.4 and Fig. 34F.5)
Suboptimal
A
Optimal
B Fig. 34F.4. A, Suboptimal needle placement with the needle superficial to the biceps tendon sheath. B, The needle is then advanced to an optimal location deep to the transverse humeral ligament and within the biceps tendon sheath.
VII
Suboptimal
Fig. 34F.5. Suboptimal needle placement using the alternative, long-axis approach with the needle tip superficial to the biceps tendon sheath within the subacromial, subdeltoid bursa. Injectate is seen filling the bursa and not the tendon sheath. The needle tip should be advanced slightly until within the sheath.
Suggested Readings Jacobson J. Fundamentals of Musculoskeletal Ultrasound. Philadelphia, PA: Saunders; 2007. Patton WC, McClusky GM III. Biceps tendinitis and subluxation. Clin Sports Med. 2001;20(3):505–529.
574
Spinner DA, Kirschner JS, Herrera JE, eds. Atlas of Ultrasound Guided Musculoskeletal Injections. New York, NY: Springer; 2014.