|1. Standard pre procedure workup (consent, indications, contraindications, allergies, document pain level if any)|
|2.Position patient recumbent with forearm supinated (palm up) with biceps tendon you are working on far side from ultrasound machine.|
|3. Scan patient looking at the biceps tendon (short axis/transverse) extra-articular and at the rotator interval. If there is fluid in the biceps tendon sheath when extra-articular, you can inject at that site. Otherwise, will need to inject at the rotator interval.|
|4. Mark needle site and ideal probe location.|
|5. Prep patient; betadine or chlorhexidine x 3. Clear wide area.|
|6. Place sterile drape and probe cover.|
|7. Draw up medications as listed in equipment list.|
|8. Place a wheal underneath the skin using a 25g needle with the 1% lidocaine at the site marked for the needle. With ultrasound guidance place the 1% lidocaine deeper within the subcutaneous tissues.|
|9. Once numb, leave 25 gauge needle in soft tissues, disconnect syringe for greater control.|
|10. With ultrasound guidance, advance the 25g needle into the sheath surrounding the tendon.|
|11. Test inject to see if easy flow with 1% lidocaine. If no resistance and see distention of the tendon sheath, exchange for 3cc syringe with injectable steroid and ropivacaine.|
|12. Scan sheath to demonstrate distention.|
|13.Pull needle out, wash skin with alcohol and place bandage on skin.
|14.Document pain level and give patient pain log.