Chapter 56: Tendon Injections

INDICATIONS

• 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

• 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

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.

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)

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 ...