This should be preformed under ultrasound guidance, as the biceps tendon is deep under the thick deltoid and impossible to 'feel' with the needle. Injecting the biceps tendon with a proteolytic steroid can also increase the risk of tendon rupture. Therefore, we prefer to use a hyaluronan (Ostenil) in young patients.
The patient sits with their arm resting by their side. Due to the great variation in humeral version, the tendon position can only be judged by rotating the arm into the best position for injection and letting the patient rest it their. The LHB tendon and groove are identified and marked on the skin with a marker. The point of injection, just lateral to the ultrasound probe is marked. The needle is directed at a 45 degree angle in the long axis of the probe, heading towards the LHB sheath and tendon. The actual tendon is not injected but rather the swollen sheath around the tendon. The injected fluid can be seen to run into the sheath.
The clinical presentation is consistent with lateral epicondylitis, which is caused from pathologic changes at the origin of the extensor carpi radialis brevis (ECRB).
Physical exam findings consistent with lateral epicondylitis include tenderness over the lateral epicondyle at the origin of the ECRB, and pain that is reproduced with gripping, resisted long finger extension, resisted wrist extension while the elbow is fully extended, and maximum passive wrist flexion. This should be distinguished with the pain with resisted supination with the arm and wrist in extension characteristically seen with radial tunnel syndrome.
Nirschl et al looked at their surgical cohort of patients with lateral epidondylitis that were treated with surgery. They found the lesion that was consistently identified at surgery was immature fibroblastic and vascular infiltration of the origin of the extensor carpi radialis brevis (ECRB). There was an over-all improvement rate of per cent, and per cent of the patients returned to full activity including rigorous sports following surgical treatment.
Morris et al used indwelling EMG to look at muscle activity about the elbow during tennis strokes in nine professional and collegiate level players. They concluded the predominant activity of the wrist extensors in all strokes may be one explanation for predisposition to injury.
Tendonitis, more properly termed tendinosis, results from acute or chronic stress of the rotator cuff tendons. Rotator cuff impingement results from repeated irritation of the rotator cuff beneath the acromial arch. 20 Repetitive overhead reaching and weight training are frequent precipitants of rotator cuff tendinosis and impingement. Rotator cuff tendinosis is diagnosed by eliciting pain or weakness with stress testing of the rotator cuff muscles. There are two common tests used for diagnosis of impingement. The Hawkins' test elicits pain with the shoulder passively flexed to 90 degrees and internally rotated. 21 The Neer's test elicits pain with passive abduction of the shoulder to 180 degrees. 22 Radiographs, if obtained, may show calcific deposits in the subacromial space or at the insertion of the supraspinatus tendon to the greater tuberosity. In cases of impingement, curvature of the acromion process may be seen.