Diagnostic Injections About the Shoulder

Edward McFarland, MD; Johnathan Bernard, MD, MPH; Eric Dein, MD; Alex Johnson, MD


J Am Acad Orthop Surg. 2017;25(12):799-807. 

In This Article

Biceps Tendon

Presentation and Evaluation

Diagnosing biceps tendon disorders is difficult for several reasons. First, the pain pattern of biceps tendon conditions, which extends into the anterior and lateral shoulder, mimics that of other disorders, including rotator cuff disease, arthritis, stiffness, and AC joint problems. Second, biceps tendon pathology is often accompanied by these disorders, so ascribing the pain to the biceps tendon rather than to a coexisting condition is often conjectural.

The physical examination for biceps tendon pathologies is hampered by similar limitations, including the coexistence of other shoulder conditions that can cause pain. Palpation of the biceps tendon is difficult in most patients because the tendon is deep in the shoulder, beneath the deltoid and the transverse ligament. Although various provocative physical examination tests are available for biceps abnormalities, most are not clinically helpful. For partial tears of the biceps tendon, Gill et al[41] found that tenderness to palpation along the long head of the tendon had a sensitivity, a specificity, and a likelihood ratio of 53%, 54%, and 1.13, respectively. They found that the Speed test had a sensitivity, a specificity, and a likelihood ratio of 50%, 67%, and 1.51, respectively.

A selective injection into the proximal biceps tendon sheath can help isolate a biceps tendon abnormality; however, blindly injecting the sheath can be difficult (Figure 10). Hashiuchi et al[42] studied 30 patients who were randomly assigned to ultrasonography-guided or unguided injection of the biceps tendon sheath. Accurate placement was observed in 13 of 15 ultrasonography-guided injections (87%) versus 4 of 15 unguided injections (27%; P < 0.05). For any injection of the bicipital groove, fluid can travel into the glenohumeral joint, creating false-positive results.

Figure 10.

Illustration of the anterior aspect of the shoulder showing the position of the needle for an injection of the biceps tendon sheath. (Copyright Louis Okafor, MD, Baltimore, MD.)

Technique Summary

The biceps tendon can be injected with the patient sitting or supine; however, the patient will be more relaxed and the arm better supported by the bed in the supine position. With the elbow bent 90°, the arm should be externally rotated 10° to 20° to bring the biceps tendon away from the anterior joint line.

Without imaging, such as ultrasonography, to locate the bicipital groove, injection of the biceps tendon is difficult. When neither ultrasonography nor fluoroscopy is used, the elbow is flexed and extended while the examiner palpates the proximal humerus to feel the tendon running beneath his or her finger. When the injection is performed, this movement of the biceps tendon can sometimes be felt at the tip of the needle. Care should be taken to avoid injecting directly into the tendon and to inject instead into the bicipital sheath or groove.