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Return to: Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Balch R, III. Balch R, III Balch, Robert, III.Tendon Injections. In: Diwan S, Staats PS. Diwan S, Staats P.S. Eds. Sudhir Diwan, and Peter S. Staats.eds. Atlas of Pain Medicine Procedures New York, NY: McGraw-Hill; 2015. http://accessanesthesiology.mhmedical.com/content.aspx?bookid=1158§ionid=64179154. Accessed May 23, 2017. MLA Citation Balch R, III. Balch R, III Balch, Robert, III.. "Tendon Injections." Atlas of Pain Medicine Procedures Diwan S, Staats PS. Diwan S, Staats P.S. Eds. Sudhir Diwan, and Peter S. Staats. New York, NY: McGraw-Hill, 2015, http://accessanesthesiology.mhmedical.com/content.aspx?bookid=1158§ionid=64179154. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager © Copyright Tools Search Book Top Return Clip Chapter 56: Tendon Injections Robert Balch, III + INDICATIONS Print Section ++ ++ The indications for tendon or ligament injections can fall into 1 of 2 categories: diagnostic and therapeutic. Infiltration of local anesthetic along the tendon sheath can confirm the suspected diagnosis through symptom relief. Indications for therapeutic injections include decreased mobility and range of motion, pain, and the need to place medication in the area of pathology as a therapeutic adjunct to other forms of treatment. Common tendon/soft tissue–related conditions for which diagnostic and therapeutic injections are indicated: Bursitis Ischial Trochanteric Pes anserine Patellar Tendinopathy/tendonosis Bicipital tendonitis Supraspinatus tendonitis De Quervain tenosynovitis Patellar tendonitis Achilles tendonitis Medial/lateral epicondylitis Levator scapulae tendonitis Enthesopathy Iliolumbar ligament Sacrococcygeal ligament Sacrotuberous ligament Sacrospinous ligament Sacroiliac ligament Interspinous ligament Supraspinous ligament Neuromas/ganglion cysts Fasciitis Plantar fasciitis Entrapment syndromes + CONTRAINDICATIONS Print Section ++ ++ Relative contraindications Needle phobia Underlying coagulopathy/bleeding diathesis Failure to respond to two previous injections Anticoagulation therapy Uncontrolled diabetes mellitus Pregnancy Absolute contraindications Local cellulitis Acute fracture Septic arthritis Bacteremia History of allergy or anaphylaxis to injectate Local tumor Inability of patient to understand consent + RELEVANT ANATOMY Print Section ++ ++ Bicipital Tendonitis/Tendonosis ++ The long head originates at the greater tuberosity of the humerus, glenoid labrum, and supraglenoid tubercle (Figure 56-1).1 The short head originates at the coracoid process. These sites are common areas of inflammation in bicipital tendonitis. Arterial supply via the circumflex humeral artery1 Most commonly the long head of the biceps becomes inflamed where it passes through the bicipital groove. The tendon may become impinged between the head of the humerus, acromion, and coracoclavicular ligaments with elevation and internal rotation of the arm. Distal inflammation along the insertional site is less common. The musculocutaneous nerve (C5C6) provides innervation to the biceps muscle. ++Figure 56-1.Anatomical depiction of the long head of the biceps inserting onto the greater tuberosity of the humerus (arrow). Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Clinical Anatomy ++ Point tenderness in the bicipital groove Anterior shoulder pain with referral to the arm Positive Yergason test—anterior shoulder pain with flexion of elbow to 90 degrees and resisted supination of the wrist ++ Levator Scapula ++ Originates at the lateral mass of C1-C4 and the tendon inserts on the superior medial angle of the scapula (Figure 56-2) Motor innervation by dorsal scapular nerve (C5) ++Figure 56-2.Anatomical depiction of the levator scapula originating at the lateral masses of C1-C4 and inserting on the superior medial angle of the scapula. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Clinical Anatomy ++ Pain along the superior medial angle of the scapula Painful, stiff neck Limited cervical rotation Pain at the angle of the neck, where the levator emerges from beneath the anterior border of the upper trapezius muscle ++ Lateral Epicondylosis/Epicondylitis ++ Wrist extensors and supinators attach to the humerus at the lateral epicondyle These muscles pass laterally over the radiocapitellar joint ++ Clinical Anatomy ++ Inflammation and enthesopathy occur with repetitive motion (Figure 56-3)—carpenters, typists, tennis players (especially backhand) “Coffee cup sign”—pain worse when holding a coffee cup or thick phone book, turning a door knob Pain worse with resistive extension ++Figure 56-3.MRI images of lateral epicondyle (T1 on the left and T2 on the right). Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Supraspinous/Interspinous Ligaments ++ The supraspinous and interspinous ligaments course from spinous process to spinous process (Figure 56-4). The supraspinous ligament is found from C7-L3 as opposed to the interspinous ligament which courses the entire length of the spine.2 Protects against spinal separation and flexion. Innervated by the medial dorsal primary rami. ++Figure 56-4.Supraspinous and interspinous ligaments. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Clinical Anatomy ++ Afferent nociceptors are activated by tearing or micro-tears in the ligament, typical of deceleration or acute flexion-extension injuries resulting in midline spine pain. Micro-tearing can lead to ligamentous laxity over time, which promotes poor posture and mechanical derangement of the spine with ensuing chronic spine pain (Figure 56-5). ++Figure 56-5.Interspinous/supraspinous ligamentous laxity depicted by the arrow from C7-T3. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Distal Piriformis ++ Originates at the anterior surface of the inferior lateral angle of the sacrum. Inserts on the medial side of the superior surface of the greater trochanter (Figure 56-6).3 In 20% of patients, all or part of the sciatic nerve passes through the piriformis muscle.3 Innervated by the piriformis nerve (L5, S1, S2). ++Figure 56-6.Distal piriformis tendon depicted inserting onto the greater trochanter. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Clinical Anatomy ++ Lateral thigh pain Buttock pain Low back pain Pain with paresthesia can be noted in the posterior thigh, and hip with radiation into the distal leg and foot Point tenderness along the posterior superior greater trochanter Symptoms aggravated by prolonged sitting and with a combination of hip flexion, adduction, and medial rotation ++ Iliolumbar Ligament ++ The iliolumbar ligament originates from the L-5 transverse and is made up of an anterior and posterior band (Figure 56-7). The anterior band is broad and flat and has two different anatomic varieties. Type 1 originates from the anterior aspect of the inferiolateral portion of the L-5 transverse process and fans out widely before inserting on the anterior portion of the iliac tuberosity. Type 2 originates anteriorly, laterally, and posteriorly from inferiolateral aspect of the L-5 transverse process and fans out before inserting on the anterior portion of the iliac tuberosity. The posterior band of the iliolumbar ligament originates from the apex of the L-5 transverse process and becomes fusiform just prior to inserting on the anterior margin and apex of the iliac crest.4 ++Figure 56-7.Iliolumbar ligament originating at L5 transverse process and inserting on the iliac crest. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Clinical Anatomy ++ Unilateral or bilateral low back pain Exquisite tender point at the posterior iliac crest (Figure 56-8) Positive hip flexion test and Patrick maneuver Constant ache aggravated by prolonged sitting and standing—referral pain to the greater trochanter and into the groin (“my testicles are in a vice”) ++Figure 56-8.Exquisite tender point at the posterior iliac crest. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + PREOPERATIVE CONSIDERATIONS Print Section ++ ++ Informed consent and proper explanation of all potential complications. Anticoagulation/bleeding diathesis/thrombocytopenia. Physical examination of the target area for singes of infection, skin ulceration or necrosis, and extent of disease. Patient must be able to lie still for the intended length of the procedure. Consider intravenous access for IV fluid and medications for sedation or hypotension if there is concern for a vasovagal reaction. Evaluation for contrast allergy—this is of the utmost importance if using fluoroscopy, since the utilization of contrast will allow for precise needle placement. This is not a concern for ultrasound-guided injections. + FLUOROSCOPIC/ULTRASOUND VIEWS Print Section ++ ++ When using fluoroscopic guidance for supraspinous/interspinous, levator, iliolumbar and distal piriformis tendon/ligament injections, always start with anterior-posterior (AP) images to confirm your location and to line up the anatomical structures. Slight cephalad tilt with ipsilateral obliquity may enhance visualization of the superior medial portion of the greater trochanter for distal piriformis tendon injections (Figure 56-20A). Cephalocaudal adjustments in the AP view should be done to square up the end plates and line up the spinous processes midline when performing supraspinous and interspinous ligament injections (Figure 56-17). Cephalad tilt with ipsilateral oblique can enhance visualization of the PSIS when performing an iliolumbar ligament injection (Figure 56-19A). Lateral views should always be done to verify depth (Figure 56-18B). ++Figure 56-18.(A) PA view of interspinous injection. (B) Contrast infiltrating the space between the L3 and L4 spinous processes. (Both the images were reproduced with permission from Lamer et al. Fluoroscopically-Guided Injections to Treat“Kissing Spine” Disease. Pain Physician: July/August 2008:11:549-554.) Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + EQUIPMENT Print Section ++ ++ 22- or 25-gauge 1.5- to 3.5-in spinal needle 30-gauge subcutaneous needle 5 cc syringe for local anesthetic/deposteroid 3 cc syringe for contrast Extension tubing + MEDICATIONS Print Section ++ ++ 0.5% bupivacaine 1% lidocaine Deposteroid Nonionic contrast (Omnipaque 240 or Isovue 300) Prep solution + INTRAOPERATIVE TECHNICAL STEPS Print Section ++ ++ Bicipital Tendon Injection ++ The tendon is palpated in the bicipital groove of the humerus. After a sterile prep and subcutaneous local anesthetic infiltration, a 25-gauge 1.5- or 2-in needle is inserted into the skin over the area of maximum tenderness and directed into the groove at an angle near parallel to the groove itself. The goal is to enter the sheath of the biceps tendon and not the tendon itself (Figure 56-9). Increased resistance to injection indicates intra-tendinous placement and the needle should be withdrawn slightly until there is very little resistance to injection.5 After negative aspiration and no resistance, 2 to 3 cc of 0.5% bupivacaine with deposteroid is injected slowly ++Figure 56-9.Bicipital tendon injection (fluoroscopy). Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Zhang et al describe an ultrasound-guided approach.6 ++ The patient is positioned supine with the torso and upper body and the ipsilateral arm alongside the body with the elbow flexed 90 degrees. The skin surrounding the needle entry point is cleaned with Betadine solution and sterile drapes placed. The ultrasound transducer is protected with a sterile cover containing a small amount of gel. A preliminary ultrasound evaluation is performed with an ultrasound unit with multi-frequency linear transducers. The transducer frequency is chosen based on the depth of the individual anatomic structure. Color Doppler is used to identify local vascular structures. On the transverse scanning of proximal humerus, the brachial bicipital groove and the biceps brachii tendon can be seen clearly (Figure 56-10A). The tendon appears as an echogenic ellipse within the groove. A lateral to medial approach using a 25-gauge, 1.5-in needle is performed. The needle is visualized in the long axis of the probe and advanced under ultrasound guidance. Once the needle tip is seen within the brachial bicipital groove, the corticosteroid is delivered under real-time monitoring (Figure 56-10B). ++Figure 56-10.(A) Transverse ultrasonogram at the level of brachial bicipital groove shows the biceps brachii tendon in the groove and the tendon appearing as an echogenic ellipse within the groove. (B) Transverse ultrasonogram of the biceps brachii tendon at the level of the brachial bicipital groove after injection of medication (corticosteroid and lidocaine). Note the distention of the peritendon sheath space and circumferential spread of medication around the tendon. (Both the images were reproduced with permission from Zhang et al. Ultrasound guided injection for the biceps brachii tendinitis: Results and Experience. Ultrasound in Med. & Biol., Vol. 37, No. 5, pp. 729–733, 2011.) Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Levator Scapula Tendon Injection ++ The patient is positioned seated, if no fluoroscopy is being used, or prone if using fluoroscopy. The tendon insertion site is marked over the superior angle of the scapula and the area of max tenderness is identified (Figure 56-11). After sterile prep, the skin is infiltrated with 1% lidocaine; then a 25-gauge 1.5-in spinal needle is inserted under fluoroscopic guidance using a coaxial technique. The needle is advanced until it contacts bone along the superior angle of the scapula (Figure 56-12). Then, the needle is walked off the bone until it is seated in the tendon sheath. After negative aspiration, 1cc of contrast is injected to ensure proper placement and no vascularization. Then, 3 cc of 0.5% bupivacaine with deposteroid is injected. Laying an RF probe across the enthesopathy may denervate the periosteum, giving pain relief (Figure 56-13). ++Figure 56-11.Levator injection site. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 56-12.Levator scapula injection without fluoroscopy. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 56-13.Radiofrequency lesion, right levator. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Lateral Epicondyle Injection ++ For the nonfluoroscopic injection, the elbow is held in the noninjecting hand, and the lateral epicondyle identified by palpation (Figure 56-14). Fluoroscopically, the radial head is identified (Figure 56-15). The radial nerve lies medial to the tendon, so the injection needs to be kept laterally. The injection is placed at the base of the tendon attachment (Figure 56-16). ++Figure 56-14.Lateral epicondyle examination. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 56-15.Fluoroscopic location of lateral epicondyle. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++Figure 56-16.Lateral epicondyle injection. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Supraspinous/Interspinous Ligament Injection ++ The patient is placed prone. After sterile preparation and drape, the spinal interspace of interest (the area of tenderness) is located by fluoroscopy (Figure 56-17). Local anesthesia of the skin and subcutaneous tissues is performed with 1% lidocaine. Then, a 22-gauge spinal needle is advanced under fluoroscopic guidance between the affected spinous processes so that the tip of the needle is placed directly between the affected spinous processes on the PA image (Figure 56-18A).7 Lateral views are then taken to verify that the needle is placed midway along the dorsal-ventral axis of the processes.7 Then, after negative aspiration, 1 cc of contrast is injected to reveal contrast spread between the targeted spinous processes (Figure 56-18B).7 This is followed by the injection of 2 cc of 0.5% bupivacaine and deposteroid. ++Figure 56-17.Midline tenderness at L5S1. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Iliolumbar Ligament Injection ++ The patient is placed prone. The target site of injection is the posterior iliac crest identified by fluoroscopy (Figure 56-19A). After sterile prep and drape, the skin and subcutaneous tissues are infiltrated with 1% lidocaine. Then a 22- or 25-gauge 3.5-in spinal needle is inserted under fluoroscopic guidance using a coaxial technique. The needle is advanced under fluoroscopic guidance until it contacts bone along the posterior iliac crest (Figure 56-19B). The needle is then walked of the bone medially until it is seated in the tendon sheath. After negative aspiration, 1 cc of contrast is injected to reveal contrast spread along the tendon and to ensure proper placement without vascularization. Then, 2 cc of 0.5% bupivacaine with deposteroid is injected. ++Figure 56-19.(A) Bone spur seen on fluoroscopy at the iliolumbar ligament insertion site. (B) Final needle placement at the iliolumbar ligament insertion site. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) ++ Distal Piriformis ++ Patient is placed prone. AP views of the lumbosacral junction and hip of the target side are visualized. Slight cephalad tilt with ipsilateral obliquity will help enhance visualization of the target at the medial superior portion of the greater trochanter (Figure 56-20A). After sterile prep and drape, the skin and subcutaneous tissues are infiltrated with 1% lidocaine. Then a 22 or 25 gauge 3.5 inch spinal needle is inserted under fluoroscopic guidance using a coaxial technique (Figure 56-20B). The needle is advanced under fluoroscopic guidance until it contacts bone along the medial superior portion of the greater trochanter. The needle is then walked of the bone medially until it is seated in the tendon sheath. After negative aspiration, 1 cc of contrast is injected to reveal contrast spread along the tendon and to ensure proper placement without vascularization. Then, 3 cc of 0.5% bupivacaine with deposteroid is injected. ++Figure 56-20.(A) Fluoroscopic view depicting the needle target along the distal piriformis tendon insertion on the greater trochanter. (B) Final needle placement at the distal piriformis insertion site. Graphic Jump Location+View Full Size|Favorite Figure|Download Slide (.ppt) + POSTPROCEDURE CONSIDERATIONS Print Section ++ ++ The patient should be followed up by telephone next day for the potential complications and immediate pain relief secondary to local anesthetic. The anti-inflammatory effect of steroid will not be apparent until 1 or 2 weeks. Patient should be advised to call pain service for any procedure related complications and/or any unexpected neurological deficit. Patient should be monitored closely for the following: Weakness Swelling Fever Bleeding Numbness Exacerbation of symptoms + POTENTIAL COMPLICATIONS AND PITFALLS Print Section ++ ++ The overall incidence of side effects after local corticosteroid injection for tendon lesions is unknown.5 Tendon rupture Exacerbation of pain Infection Nerve damage Weakness Numbness Damage to the tendon itself Allergic reaction to the injectate Tissue atrophy + CLINICAL PEARLS Print Section ++ ++ As early as 1930, Leriche pointed out that, after infiltration of a tender ligament or tendon with procaine, there was not just temporary relief of discomfort but a more prolonged effect than what one would expect from the anesthesia.8 Corticosteroid injections are one of the most commonly used treatments for chronic tendon lesions. Despite their popularity, the evidence for long-term effectiveness is lacking.5 Many of the studies have had inadequate design. Problems include small sample sizes, unsuitable outcome measures, short term follow up, inadequate blinding, lack of a true placebo, and the inclusion of heterogeneous study populations.5 Tendinitis may be inflammatory, but the primary problem is often degeneration with attempted repair, ie, tendinopathy or tendinosis rather than true tendinitis.9 + REFERENCES Print Section ++ +1. +Ahrens et al.. The long Head of the biceps and associated tendinopathy. J Bone Joint Surg. 2007 Aug;89-B(8). +2. +Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. New York: Demos Medical Publishing; 2004:153–154, 264. +3. +Travell J, Simons D. Travell and Simons’ Myofascial Pain and Dysfunction, the Trigger Point Manual. Pages 187, 188, 191, 192, 193. +4. +Rucco et al.. Anatomy of the iliolumbar ligament: a review of its anatomy and a magnetic resonance study. Am J Phys Med Rehabil. 1996 Nov-Dec;75(6):451–455. +5. +Speed CA. Corticosteroid injections in tendon lesions. BMJ. 2001 Aug18;323. +6. +Zhang J, Ebraheim N, Lause GE. Ultrasound guided injection for the biceps brachii tendonitis: results and experience. Ultrasound Med Biol. 2011;37(5):729–733. +7. +Lamer et al.. Fluoroscopically-guided injections to treat “kissing spine” disease. Pain Physician. 2008 Jul/Aug;11:549–554. +8. +Naeim F. Treatment of the chronic iliolumbar syndrome. West J Med. 1982 Apr;136(4):372–374. +9. +Rasmussen OS. Sonography of tendons. Scand J Med Sci Sports. 2000;10:354–360. +10. +Mitra et al.. Interspinous ligament steroid injections for the management of Baastrup’s disease: a case report. Arch Phys Med Rehabil. 2007 Oct;88:1353–1356. +11. +Nosir HR. Upper extremity joint injections. In: Manchikanti L, Singh V, eds. Interventional Techniques in Chronic Non-Spinal Pain. Paducah, KY: ASIPP Publishing; 2009:361–388.