Ultrasound-Guided Biceps Peritendinous Injections in the Absence of a Distended Tendon Sheath

Transcription

1 TECHNICAL INNOVATION Ultrasound-Guided Biceps Peritendinous Injections in the Absence of a Distended Tendon Sheath A Novel Rotator Interval Approach Taylor J. Stone, MD, Ronald S. Adler, MD, PhD This retrospective study evaluated the technical success rate of a novel injection into the long head of the biceps tendon sheath by a rotator interval approach in 26 patients. A 25-gauge, 1.5-in needle was positioned into the rotator interval from a lateral approach, where a therapeutic injection was performed. Postinjection sonograms images were reviewed to assess for fluid within the sheath to calculate the technical success rate. Fluid distention of the biceps tendon sheath was shown in all 26 cases, corresponding to a 100% technical success rate. In addition, postinjection ultrasound imaging of the anterior shoulder provided additional diagnostic findings in 6 of 26 patients (23%). Key Words biceps tendinitis; injection; musculoskeletal ultrasound; tenography Received February 9, 2015, from the Department of Radiology, New York University Langone Medical Center and Hospital for Joint Diseases, New York, New York USA. Revision requested February 17, Revised manuscript accepted for publication March 14, Address correspondence to Taylor J. Stone, MD, Department of Radiology, New York University Langone Medical Center and Hospital for Joint Diseases, 301 E 17th St, Sixth Floor, New York, NY USA. taylor.stone.md@gmail.com Abbreviations LHBT, long head of the biceps tendon doi: /ultra The long head of the biceps tendon (LHBT) originates from the superior glenoid labrum and supraglenoid tubercle. The LHBT courses obliquely through the rotator interval, where it is cradled by the superior glenohumeral ligament medially and the coracohumeral ligament laterally 1 (Figure 1). The LHBT exits the rotator interval within the intertubercular groove, between the greater and lesser tubercles. The tubercles are bridged anteriorly by the intertubercular ligament, formed principally from subscapularis tendon fibers, keeping the LHBT within the groove. The LHBT is intra-articular but extrasynovial, as the tendon sheath is contiguous with the glenohumeral joint synovium before ending in a blind pouch at the distal groove. 2 Accordingly, it is common to see a tendon sheath effusion in the setting of glenohumeral joint effusions. Ninety percent of patients with proximal LHBT sheath effusions have abnormalities elsewhere in the glenohumeral joint. 3 Tendinosis of tears of the LHBT may occur in isolation or in combination with other shoulder disorders. 4 Accurate LHBT sheath injection is important, both diagnostically and therapeutically, in patients with anterior shoulder pain. Peritendinous injections most commonly use a steroid and an anesthetic to produce the desired anesthetic and anti-inflammatory properties. However, steroids should not be injected directly into tendons, as doing so predisposes the tendon to rupture by the American Institute of Ultrasound in Medicine J Ultrasound Med 2015; 34:

2 Figure 1. Anatomy of the LHBT. A, Short-axis sonogram of the rotator interval showing the components of the biceps pulley complex: coracohumeral ligament lateral fibers (CHL), superior glenohumeral ligament (SGHL) as it inserts onto the fovea capitas, subscapularis tendon (SCT), and supraspinatus tendon (SST). B, Sagittal oblique image from a magnetic resonance arthrogram obtained at approximately the same anatomic level as A showing the corresponding anatomy, with the coracohumeral ligament lateral fibers (open arrow) and superior glenohumeral ligament (white arrow). Improved injection accuracy with the use of ultrasound guidance has been demonstrated compared to blind injection techniques. 6 With LHBT disorders, the tendon sheath typically contains fluid. In that case, the needle is directed into the fluid, followed by injection of the anesthetic/steroid mixture. Otherwise, the needle is commonly directed along the superficial tendon margin, and a test injection of a local anesthetic is used to confirm local distention of the sheath before injecting steroids. When there is no tendon sheath effusion, there is only a 2-mm space in which to place the needle, and care must be taken not to move the needle tip when exchanging syringes to prevent injecting the steroid-containing mixture directly into the tendon or into the adjacent tissues. 3 To inject patients safely in the absence of a tendon sheath effusion, we investigated placing the tip of the needle adjacent to the biceps tendon in the lateral aspect of the rotator interval, where we have observed greater flexibility in needle placement while still ensuring adequate distension of the LHBT tendon sheath during therapeutic injection. Materials and Methods Patient Selection This retrospective study was approved by the local Institutional Review Board and complied with local ethical standards. All patients were referred to radiology for an ultrasound-guided biceps tendon sheath injection. Patients were referred from local orthopedic surgery, rheumatology, or sports medicine practices. The clinical indication for LHBT sheath injection was determined by the referring physicians, and indications for injection were for diagnostic and therapeutic purposes. Informed consent for the procedure was obtained in the Department of Radiology just before the procedure after explanation of the procedure itself, its potential complications, and alternative therapies. Inclusion and Exclusion Criteria The study included patients referred to the Department of Radiology for biceps tendon sheath injection between March 2012 and May The routine injection protocol includes a preprocedure ultrasound (Acuson S2000; Siemens Medical Solutions, Mountain View, CA) examination of the biceps tendon by both an experienced, dedicated musculoskeletal sonographer and an attending musculoskeletal radiologist with 25 years of ultrasound experience. A linear 14-MHz transducer was used, and the arm was placed in external rotation with the patient supine (Figure 2). If fluid was present within the LHBT sheath, then a direct intrasheath injection was performed by directing the tip of the needle into the fluid (Figure 3). If no fluid was seen within the LHBT sheath, then a peritendinous injection was performed in the rotator interval (Figure 4). Exclusion criteria included prior biceps tenotomy/tenodesis and allergy/intolerance to the local anesthetics or steroid; none of the patients without LHBT sheath effusions were excluded J Ultrasound Med 2015; 34:

3 Figure 2. Ultrasound examination performed with the patient supine and arm in external rotation. Figure 3. Direct injection of the sheath effusion. The needle tip (white arrow) enters the LHBT sheath effusion (open arrow). Description of Procedure After documenting no sonographically detectable effusion within the LHBT sheath, the transducer was moved more proximally, and an image of the LHBT was obtained in the lateral aspect of the rotator interval. A target was drawn with a disposable marker on the skin along the lateral aspect of the transducer using. The skin and transducer were then prepared and draped in a sterile fashion. One percent lidocaine (Xylocaine; Astra Zeneca, North Ryde, New South Wales, Australia) was used for all subcutaneous anesthesia. Using ultrasound guidance, with the LHBT visualized within the lateral aspect of the rotator interval, a 25-gauge, 1.5-in needle was advanced from a lateral approach to a position adjacent to the tendon. The lidocaine was injected through the needle to confirm the peritendinous location of the needle tip before a 3-mL mixture of 1 ml of triamcinolone, 40 mg/ml (Kenalog-40; Bristol-Meyers-Squib, Princeton, NJ), and 2 ml of 0.5% ropivicaine (Naropin; Fresenius Kabi, Bad Homburg, Germany) was then injected. After injection, an ultrasound examination of the proximal LHBT sheath was performed to evaluate for injectate filling the sheath. The skin was cleansed and a bandage applied. Assessment of immediate pain relief in the presence of the local anesthetic was documented in the radiology reports for most patients (15 of 26), and responses were either no relief, partial relief, or complete relief. The patients were discharged and instructed to notify the Department of Radiology for any complications. The patients clinical charts and follow-up appointment notes were retrospectively reviewed. Results Twenty-six patients (11 men and 15 women) who presented for biceps tendon injection during this time frame did not have LHBT sheath effusions and were included in the study. There were 17 right and 11 left arm injections. The mean age of the study population ± SD was 45.5 ± 10.7 years. Postprocedure ultrasound examinations of the proximal tendon sheath showed injectate filling the tendon sheath in all 26 patients (100%). Postprocedure ultrasound examinations of the proximal biceps tendon sheath showed incidental diagnostic findings in 6 patients (23%), including a subscapularis tendon tear (1 patient), LHBT sheath synovial cysts (2 patients), LHBT split tears (2 patients), and anterior supraspinatus calcific tendinitis (1 patient; Figure 5). Of the 15 patients who had immediate postprocedural pain levels recorded, 8 (53%) reported complete pain relief; 6 (40%) reported partial pain relief; and 1 (7%) reported no pain relief. The patient who reported no immediate pain relief had anterior supraspinatus calcific tendinitis on the postprocedure ultrasound examination. No complications were reported after the injection. Three patients (11.5%) eventually underwent arthro - scopy. The patient who reported no immediate postprocedural pain relief with an ultrasound diagnosis of calcific tendinitis underwent biceps tenodesis, and a mildly inflamed intra-articular LHBT was noted at arthroscopy. The second patient, who reported partial pain relief after the procedure, was noted to have loose sutures from a prior labral repair encircling an inflamed intra-articular LHBT. The third patient reported complete postprocedural pain J Ultrasound Med 2015; 34:

4 relief but had recurrent pain after the injection and was found to have a type 1 superior labral anterior-to-posterior tear and a partial-thickness articular-sided rotator cuff tear, which were both repaired. The biceps tendon was found to be normal. Discussion The intra-articular LHBT is innervated by sensory sympathetic nerve fibers and is a substantial pain generator in the anterior shoulder. 7 Pain from the LHBT is typically located over the anterior aspect of the shoulder, over the bicipital groove. 8 On clinical examination, provocative tests such as the Speed and Yergason tests are used to elicit bicipital groove pain, suggestive of LBHT origin. 9 Figure 4. Ultrasound-guided injection at the rotator interval. A, Injection into the lateral part of the rotator interval is done from a lateral approach. (A 3.5-in needle is used here for visualization, but only a 1.5- in needle is typically needed.) B, Sonogram showing the needle tip (white arrow) adjacent to the LHBT within the rotator interval. The coracohumeral ligament is depicted at this level (open arrow). C, Ultrasound evaluation of the LHBT (arrow) without a sheath effusion before injection. D, Ultrasound evaluation of the LHBT after injection showing injectate (arrow) filling the tendon sheath J Ultrasound Med 2015; 34:

5 Ultrasound-guided LHBT peritendinous injection at the lateral aspect of the rotator interval is a safe and effective technique when no tendon sheath effusion is seen. Injecting adjacent to the tendon within the bicipital groove in the absence of an effusion may be more difficult, as there is little room for error, potentially subjecting patients to inaccurate delivery of steroids outside the tendon sheath or possibly within the tendon itself. The imaging workup of anterior shoulder pain typically begins with shoulder radiographs, which may show osseous/mineralized etiologies of anterior shoulder pain. Routine diagnostic ultrasound imaging, often with a dynamic evaluation, is a cost-effective way to evaluate anterior shoulder pain. However, routine non contrastenhanced shoulder magnetic resonance imaging is more commonly used to evaluate anterior shoulder pain at our institution unless an intra-articular disorder is specifically suspected on the basis of the physical examination and clinical history, in which case magnetic resonance arthrography is requested. Conservative therapy, ie, rest and nonsteroidal antiinflammatory medications, is typically the first-line treatment of all LHBT disorders. 10 However, in refractory cases of inflammatory biceps tendinitis, local peritendinous injection of anesthetic and corticosteroids has a role. 11 Pain relief from the injection has important diagnostic implications, and accurate delivery is important. In cases of persistent pain, surgical intervention is warranted, and options include tenotomy, tenodesis, and superior labral repair, based on the functionality and cosmesis requirements of the patient. 10 In our study, distention of the LHBT sheath after injection in all 26 patients confirmed a 100% technical success rate, leading us to conclude that the location provides a reliable means of LHBT sheath injection in the absence of a sheath effusion. Only 1 of 15 patients (7%) in our study population did not obtain any immediate relief in the presence of the local anesthetic. This patient had anterior Figure 5. Postinjection diagnostic tenosonographic findings. A, Hyperechoic injectate insinuates along the superficial margin of the intra-articular biceps deep to the coracohumeral ligament (arrow). B, Anterior shoulder sonogram showing a hyperechoic intratendinous deposit with posterior acoustic shadowing (arrow), consistent with anterior supraspinatus calcific tendinitis. C, Hyperechoic reflectors with dirty shadowing consistent with gas bubbles insinuate within the subscapularis tendon and track medially (arrow), consistent with a partial-thickness insertional intrasubstance subscapularis split tear. It should be noted that these microbubbles lie medial to the site of injection, which used a lateral approach. J Ultrasound Med 2015; 34:

6 supraspinatus calcific tendinitis noted on the postprocedure ultrasound examination, which may have contributed to his pain. However, at the time of his arthroscopic examination, a subjectively mildly inflamed intra-articular LHBT was noted. Interestingly, another patient who had complete pain relief went to arthroscopy and had a grossly normal intra-articular LHBT in the setting of superior labrum and rotator cuff tears. His relief may have been from intraarticular administration of the anesthetic or from a placebo effect, or he may have had biceps tendinitis that resolved after the injection of the anesthetic/steroid, only to be bothered subsequently by his cuff disease. A quick postprocedure ultrasound examination demonstrated diagnostic utility in our study, revealing diagnostic findings in 23% of the patients. In essence, if the amount of gas injected into the tendon sheath is limited, then a tenosonogram is obtained at the time of injection, in which fluid distention of the tendon sheath allows for a dedicated ultrasound evaluation of the sheath. From our institution s unpublished experience, thick and nodular synovial tissue proliferation indicative of tenosynovitis is more conspicuous when the tendon sheath is distended. Furthermore, pressurization of the sheath leads to imbibition of hypoechoic injectate into LHBT tears, similar to that seen in the labrum or meniscus on traditional computed tomographic/magnetic resonance arthrograms. Triamcinolone was the corticosteroid used in our study, and as a particulate agent, it has acoustic reflective properties, making its distribution conspicuous. 12 Furthermore, with therapeutic injections, a small amount of gas is injected at the conclusion of the injection, with air bubbles that can imbibe into pathologic sites (Figure 5C). In conclusion, in our experience, injection of the LHBT at the lateral aspect of the rotator interval provides a safe, reliable means of LHBT sheath injection in the absence of a tendon sheath effusion, providing an alternative to the traditional method of placing the needle adjacent to the more distal extra-articular LBHT. Furthermore, our study indicates that there is some value in a quick postprocedure ultrasound evaluation of the extra-articular biceps tendon, as a tenosonographic effect may delineate abnormalities of the anterior shoulder. 3. Middleton WD, Reinus WR, Totty WG, Melson CL, Murphy WA. Ultrasonographic evaluation of the rotator cuff and biceps tendon. J Bone Joint Surg Am 1986; 68: Briggs M, Safaii S, Beall DL; American Dietetic Association; Society for Nutrition Education; American School Food Service Association. Position of the American Dietetic Association, Society for Nutrition Education, and American School Food Service Association nutrition services: an essential component of comprehensive school health programs. J Am Diet Assoc 2003; 103: Unverferth LJ, Olix ML. The effect of local steroid injections on tendon. J Sports Med 1973; 1: Hashiuchi T, Sakurai G, Morimoto M, Komei T, Takakura Y, Tanaka Y. Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg 2011; 20: Alpantaki K, McLaughlin D, Karagogeos D, Hadjipavlou A, Kontakis G. Sympathetic and sensory neural elements in the tendon of the long head of the biceps. J Bone Joint Surg Am 2005; 87: Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999; 8: Holtby R, Razmjou H. Accuracy of the Speed s and Yergason s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy 2004; 20: Ding DY, Garofolo G, Lowe D, Strauss EJ, Jazrawi LM. The biceps tendon: from proximal to distal AAOS exhibit selection. J Bone Joint Surg Am 2014; 96:e Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician 2009; 80: Luchs JS, Sofka CM, Adler RS, Sonographic contrast effect of combined steroid and anesthetic injections: in vitro analysis. J Ultrasound Med2007; 26: References 1. Beltran LS, Beltran J, Biceps and rotator interval: imaging update. Semin Musculoskelet Radiol 2014; 18: Lam F, Mok D. Treatment of the painful biceps tendon: tenotomy or tenodesis? Curr Orthop 2006; 20: J Ultrasound Med 2015; 34: