Long Head of Biceps Brachii Tendon Sheath Injection

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Long Head of Biceps Brachii Tendon Sheath Injection
Indication Pain, diagnostic injection, alternative access to the glenohumeral joint
Syringe 3-5mL
Needle 25 or 27-gauge 40mm needles, 25 gauge Quincke needle (larger patients)
Steroid 40mg triamcinolone
Local up to 5mL lidocaine 1%

Long head of biceps brachii (LHB) tendon sheath injections under ultrasound-guidance ensures accurate delivery of injectate, which is important as these injections are often performed for diagnostic purposes.



  • pain
  • diagnostic injection
  • alternative access to the glenohumeral joint (shoulder)

The tendon sheath is continuous with the glenohumeral joint. And so fluid in the sheath may indicate glenohumeral joint pathology, and a shoulder joint injection may be more appropriate.


  • Absolute: anaphylaxis to contrast/ injectates, active local/ systemic infection
  • Relative: bleeding diathesis, recent injection with steroid in same/ other body parts, long head of biceps and/ or rotator cuff tendon tears, unable to remain still for the procedure, young age

Pre-procedural Evaluation

Relevant imaging should be reviewed, and details of the patient confirmed. The patient should have an opportunity to discuss the risks and benefits and consent obtained. A focussed pre-procedure ultrasound is usually performed.

Risks include: infection, bleeding, allergy, focal fat necrosis/ skin discolouration at injection site, complete tendon tear


  • ultrasound machine, sterile probe cover and a skin marker
  • skin cleaning product
  • sterile drape
  • sterile field and tray for sharps
  • syringe selection i.e. 5mL and 3mL
  • larger bore drawing up needle
  • needle to administer local anaesthetic i.e. 30 or 25-gauge needle
  • needle to cannulate the tendon sheath i.e. 25 or 27-gauge needle
  • injectants i.e. local anaesthetics, iodinated contrast, corticosteroid preparation
  • sterile gauze
  • adhesive dressing/ band aid


The general principles of guided injections are to:

cannulate the structure under image guidance administer injectate under visualisation, usually a corticosteroid and a small amount of longer-acting local anaesthetic, and avoiding intra-tendinous injection

Ultrasound Guided

  • optimise patient positioning by lying them flat and supine or with minimal upright bed angulation with the target arm straight, by their side with the hand supinated, targeting a lateral access
  • identify the LHB tendon in the transverse plane; perpendicular to the long axis, optimise imaging and mark a lateral skin entry point
  • clean skin and draw up appropriate medications
  • consider local anaesthesia along the proposed needle path
  • under ultrasound guidance using lateral approach, insert the needle in-plane with the probe into the lateral and inferior aspect of the LHB tendon sheath
  • the needle tip position can be checked with a small amount of injected local anaesthetic, which should flow freely
  • administer steroid containing injectate under direct visualisation, avoiding intra-tendinous injection
  • removed needle and apply dressing/ band-aid as required
  • pain diary given if a diagnostic injection

Fluoroscopy Guided

Landmark Guided


The most serious complication is infection. Steroid containing injections should be postponed if there are signs and/or symptoms of local and/ or systemic infection. Fat necrosis causing skin dimpling and skin discolouration can occur due to steroid leaking into the surrounding soft tissues



See Also

External Links


Part or all of this article or section is derived from Long head of biceps brachii tendon sheath injection (technique) by Dr Dai Roberts et al., used under CC BY-NC-SA 3.0

  1. Gofeld M, Hurdle MF, Agur A. Biceps Tendon Sheath Injection: An Anatomical Conundrum. (2019) Pain medicine (Malden, Mass.). 20 (1): 138-142. doi:10.1093/pm/pny051 - Pubmed
  2. Park SK, Choi YS, Kim HJ. Hypopigmentation and subcutaneous fat, muscle atrophy after local corticosteroid injection. (2013) Korean journal of anesthesiology. 65 (6 Suppl): S59-61. doi:10.4097/kjae.2013.65.6S.S59 - Pubmed

Literature Review