High Yield Topics

Biceps Tendinitis

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Ovid: 5-Minute Sports Medicine Consult, The


Biceps Tendinitis
Stephen Huang
Jason M. Leinen
Basics
Description
  • Overuse injury of the long head of the biceps
  • Initially begins as inflammation in the tendon sheath known as tenosynovitis and then progresses to tendon degeneration and disordered arrangement of collagen fibers, otherwise known as tendinosis or biceps tendinopathy
  • Primary biceps tendinitis (inflammation of the tendon) is estimated to represent only 5% of cases.
Risk Factors
Repetitive use of upper extremities (especially overhead), such as throwing/hitting, swimming, racquet sports, and gymnastics
Etiology
  • Anatomy:
    • The long head of the biceps arises from the superior glenoid labrum and the supraglenoid tubercle of the scapula.
    • It is an intraarticular but extrasynovial structure.
    • Primary blood supply proximally is the anterior humeral circumflex artery.
  • Biomechanics:
    • Primary function of the biceps at the elbow is as a flexor and supinator.
    • In the shoulder, the biceps tendon may act as a humeral head depressor and a secondary stabilizer of the glenohumeral joint.
    • During throwing, it assists in deceleration of the humerus.
Commonly Associated Conditions
  • Rotator cuff pathology (tendinopathy, impingement, tears)
  • Glenoid labral tears (SLAP lesions)
  • Subluxation/dislocation of the long head of the biceps
  • Biceps tendon rupture
Diagnosis
History
  • Anterior shoulder pain localized over the bicipital groove, which may radiate distally toward the biceps
  • Pain is aggravated by overhead activities or lifting objects.
Physical Exam
  • Point tenderness over the bicipital groove
  • An audible or palpable snap during arc of motion while throwing may indicate instability or subluxation of the biceps tendon.
  • A large mass (“Popeye deformity”) in the upper arm, ecchymosis, and swelling following a painful audible pop with quick resolution of pain could indicate biceps tendon rupture.
  • Any positive testing for biceps tendon pathology may also signify a glenoid labral tear (SLAP lesion).
  • Special tests:
    • Speed test: With the patient's shoulder elevated to 90 degrees of forward flexion, elbow extended and forearm supinated, the patient flexes the shoulder against resistance. Pain in or about the bicipital groove is considered a positive test.
    • Yergason test: With the patient's elbow flexed to 90 degrees, the patient supinates against resistance. Pain over the biceps tendon in the bicipital groove is considered a positive test.
Diagnostic Tests & Interpretation
Imaging
  • Plain-film radiographs are not helpful in the diagnosis of biceps tendon pathology but may reveal abnormalities of the acromion process such as hooking or spurring associated with rotator cuff impingement.
  • MRI may show increased signal on T2-weighted images in the area of the biceps tendon. MRI is also useful in detecting pathology of the superior labrum and rotator cuff and is noninvasive.
  • MR arthrography is superior to conventional MRI in evaluating the glenoid labrum and rotator cuff but is invasive.
  • Dynamic US is becoming more popular in diagnosing biceps tendon rupture, subluxation, and dislocation. It is not reliable in evaluating intra-articular tears or the glenoid labrum. US is very operator- and facility-dependent. Advantages include low cost and lack of radiation exposure.
Differential Diagnosis
  • Rotator cuff tendinopathy
  • Impingement syndrome
  • Glenoid labral tears
  • Biceps tendon subluxation/dislocation
  • Subacromial bursitis
  • Acromioclavicular joint separation or arthritis
  • Pectoralis minor strain
  • Glenohumeral joint arthritis
  • Thoracic outlet syndrome
  • Cervical disk disease
  • Brachial plexus injuries
  • Rheumatoid arthritis
  • Pancoast tumor

P.49


Treatment
Acute treatment:
  • Conservative measures include rest, ice, and NSAIDs.
  • Rest should not include prolonged immobilization because this may lead to adhesive capsulitis (frozen shoulder).
  • Gentle stretching and range-of-motion (ROM) exercises should be initiated early, once symptoms begin to improve.
  • Consider physical therapy for persistent symptoms.
  • Surgery is reserved for refractory cases.
Additional Treatment
Additional Therapies
  • Physical therapy:
    • Gentle ROM exercises are begun 1st.
    • Scapulothoracic stabilization exercises
    • Rotator cuff strengthening
    • Biceps strengthening
  • Include:
    • US: Uses sound waves to heat up the affected tissues
    • Phonophoresis: Uses US waves to drive topical corticosteroid medication into the affected tissue
    • Iontophoresis: Uses electric current to drive a corticosteroid into the affected tissue
Surgery/Other Procedures
  • Injections:
    • Corticosteroid injection into the biceps tendon sheath may be considered, but controversy exists regarding the accuracy of such injections.
    • Injection into the tendon itself has been associated with tendon rupture and should be avoided.
  • Surgical options may be considered for patients who fail conservative treatment or have refractory pain.
    • Tenotomy: Surgical release of the long head of the biceps tendon at or near its superior glenoid labral origin:
      • Recommended in older patients with low activity requirements
      • Disadvantage includes a cosmetic “Popeye deformity” and possible loss of some strength with supination.
      • Minimal rehabilitation is required.
    • Tenodesis: Fixation of the long head of the biceps tendon in the bicipital groove
      • Minimal loss of function compared with tenotomy
      • No cosmetic defect
      • Recommended in younger, more active individuals
      • Disadvantages include a more complex operation, a period of immobilization, and longer postoperative rehabilitation.
  • Proximal rupture of the long head of the biceps typically relieves symptoms of pain without significant loss of function. Surgery may be considered if there is significant loss of strength or function.
Reference
1. Longo UG, Franceschi F, Ruzzini L, et al. Characteristics at haematoxylin and eosin staining of ruptures of the long head of the biceps tendon. Br J Sports Med. 2007.
Additional Reading
Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007;89-B:1001–1009.
Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 2009;80:470–476.
Friedman DJ, Dunn JC, Higgins LD, et al. Proximal biceps tendon: injuries and management. Sports Med Arthrosc. 2008;16:162–169.
Patton WC, McCluskey GM. Biceps tendinitis and subluxation. Clin Sports Med. 2001;20:505–529.
Simmon SM, Dixon JB. Biceps tendinopathy and tendon rupture. www.uptodate.com. version 17.2. March 5, 2009. 1–14.
Codes
ICD9
726.12 Bicipital tenosynovitis
Clinical Pearls
  • Primary biceps tendinitis is very rare and thought to be ∼5% of cases.
  • Studies involving biopsies of biceps tendons show an absence of inflammatory cells in the tendon itself.
  • Instead they have shown collagen degeneration and disordered arrangement of collagen fibers (1).


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