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.