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Ultrasound guided distal biceps tendon injection
What is distal biceps tendon pain?
The biceps is the big muscle at the front of the upper arm. It has two parts (the short and the long heads) and two important functions. One is to bend/flex the arm (like when doing biceps curls in the gym). The other is to rotate the elbow and wrist inward (like when using a screwdriver). The distal biceps tendon is the part of the tendon at the level of the elbow joint. It attaches to the radial tuberosity (bony prominence at the upper forearm). Usually, the distal biceps tendon consists of two parts belonging to the short and long heads of the muscle. Distal biceps tendon problems usually result in pain at the front of the elbow. It is commonly seen when there is overload upon the tendon, like in those who lift heavy weights during biceps curls in the gym and manual workers.
What is distal biceps tendonitis?
Distal bicep tendon pain can be secondary to tendon inflammation (tendinitis) or tear. Bicipital radial bursitis is another condition that can be seen separately or in association with distal biceps tendinitis. It refers to inflammation of the bursa (thin sac of fluid) between the distal biceps tendon and its attachment to the bone (the radial tuberosity).
What are the symptoms of distal biceps tendinitis?
Dull pain just below the level of the elbow.
Certain exercises like biceps curls and bar pull-ups can increase the pain.
The pain may result in forearm weakness.
If there is a significant biceps tendon tear, the patient usually reports a certain incident of injuring the elbow while performing sport or other activity. This can be associated with a pop and bruising. It is important to see a doctor urgently as surgical treatment might be needed. The outcome from surgical treatment is best if the surgery is performed within 3 weeks of the injury.
How to diagnose the cause of distal biceps pain?
It is important to have a diagnostic ultrasound to confirm the extent of inflammation or injury of the distal biceps tendon. The technique for ultrasound examination of the distal biceps tendon can be challenging. Dr Al-Ani has published a paper about the different ultrasound techniques for assessing the distal biceps tendon. MRI examination is also useful to assess the distal biceps tendon, especially when the ultrasound findings are equivocal and when there is uncertainty about the diagnosis, as the MRI can assess the internal joint structures and ligaments in more detail.
Ultrasound guided distal biceps tendon injection therapy
Most cases of distal biceps tendonitis will settle with conservative measures like exercise modification and anti-inflammatory tablets. In difficult cases, Steroid injections can be considered, especially if there is an inflamed bicipital radial bursa. Steroids should never be injected directly into the tendon or a tendon tear as they can possibly weaken the tendon. Therefore, when the pain is purely due to biceps tendinitis, we prefer to perform ultrasound guided tendon fenestration or platelets-rich plasma (PRP) injection. In tendon fenestration/tenotomy, a small needle is used to fenestrate the inflamed tendon multiple times under ultrasound guidance. This is thought to result in micro injury and the release of factors that help tendon healing. In ultrasound guided PRP injection, a blood sample is taken from the patient's vein and put in a special centrifuge machine to separate its different components. The layer on the top is called “the plasma”, which contains platelets and other useful growth factors. This is injected into the tendon under ultrasound guidance to help stimulate healing. Please see PRP injections for more details.
The Musculoskeletal Ultrasound & Injections clinic
169 Richmond Road
Kingston upon Thames
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