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The Biceps Long‐Head Tendon: An Overlooked Pain Origin for Ultrasound‐Guided Injection

To the Editor The long head of the biceps brachii tendon plays a crucial role in anterior shoulder pain. We would like to congratulate the team of Dr Geannette for their retrospective analysis of cases undergoing ultrasound-guided injection to the biceps tendon sheath. In the study, the authors found that 43% of the patients had a normal ultrasound appearance of the biceps tendon, followed by 36.6% with biceps tendinosis. A more interesting finding was that the ultrasound presentation of the biceps tendon was normal in half of the participants who reported postinjection pain relief. Therefore, the authors concluded that a normal-appearing biceps tendon and sheath should not stop physicians from conducting biceps peritendinous injection in cases with anterior shoulder pain. In their study, the biceps tendons had merely been investigated at the bicipital sulcus. A well-known fact is that most of pathologic biceps tendons are secondary to rotator cuff tendon disorders. Therefore, if the portion at the rotator cuff interval level had been checked, there would have been more abnormal ultrasound findings of the biceps tendons. Recently, some techniques have been developed to visualize the intra-articular portion of the biceps tendons. With the use of a curvilinear transducer and proper positioning, the labral attachment of the biceps tendons can be appraised by ultrasound, which has shown its utility in diagnosis of superior labrum anterior-to-posterior lesions. Furthermore, the authors are suggested to include the most prevalent biceps tendon disorder, bicipital peritendinous effusion, into the analysis. Once the effusion thickness is greater than 1 mm, there is a higher probability of observing various rotator cuff problems in the same shoulders. Therefore, we believe that if the bicipital peritendinous effusion had been taken into consideration in this study, the portion of patients with entirely normal biceps tendons would have been substantially reduced. Despite some limitations due to the retrospective nature of this study, the authors did provide solid evidence of the usefulness of corticosteroid injection into the biceps tendon sheath. Subacromial impingement syndrome is the most common cause of anterior shoulder pain, and a dynamic ultrasound study had proven the positive association between subacromial impingement and bicipital peritendinous effusion. Recently, a randomized controlled double-blind trial showed that ultrasound-guided dual-target (subacromial bursa plus proximal biceps long-head tendon) corticosteroid injection had an extended duration of symptom relief compared with standard subacromial injection. In the