by Derek Speaker
Biceps tendinitis is inflammation of the long head of the biceps tendon. This condition is typically seen in a younger, athletic population and is usually caused by repetitive overhead motions. Pain in the anterior shoulder that is described as a “deep throbbing ache” is typically the most common complaint among patients and is also accompanied by weakness. Biceps tendonitis typically occurs with other shoulder problems, most notably, the rotator cuff. Conservative treatment is the best option for patients even though surgery can be used in severe cases. Nonsteriodal anti-inflammatory drugs (NSAIDs), ice, rest from aggravating activities such as throwing or other overhead motion, stretching, and strengthening exercises are some of the common ways to manage biceps tendinitis.
The long head of the biceps tendon begins at the supraglenoid tubercle of the scapula and the short head begins at the tip of the coracoid process. The long head is extra-synovial and intra-articular and the tendon itself is roughly 9 cm long. Crossing the anterior surface of the humeral head, the biceps tendon exits the shoulder joint via the bicipital groove. The tendon stays secure within the bicipital groove due to the transverse humeral ligament which runs perpendicular to the tendon of the long head and attaches to the greater and lesser tubercles of the humerus. Distally, the bicep attaches to the tuberosity of the radius and fascia of the forearm via the bicipital aponeurosis. The long head of the biceps tendon has been shown to receive sensory and sympathetic innervations. The anterior circumflex humeral artery supplies blood to the long head of the biceps and also runs along the bicipital groove. The biceps brachii functions to supinate the forearm and flex the elbow. The long head of the biceps also functions to stabilize the shoulder joint when heavy weight is carried through the upper extremities. Abduction of the humeral head places the attachment of the biceps tendon under the acromion along with the rotator cuff. External rotation at or above the horizontal level compacts these structures against the anterior acromion causing irritation. These repeated motions lead to inflammation and degenerative changes.
Primary biceps tendinitis (inflammation of the biceps tendon with no other pathologic changes in the shoulder) occurs in roughly 5% of all patients with biceps tendinitis. Of all patients with biceps tendinitis, 95% usually have another injury associated with the tendinitis such as a tear in the rotator cuff or a superior labrum anterior to posterior (SLAP) lesion. Typically, those who experience pathology affecting the biceps tendon are in the age range of 18 to 35 years old. Individuals who play sports involving overhead motion such as baseball, softball, swimming are more susceptible to biceps tendinitis.
Potential Etiologies 3,7
Damage to the biceps tendon is usually caused by repetitive, overhead activities. This wear and tear can cause many microscopic changes including but not limited to fissuring, fibrocyte proliferation, atrophy of collagen fibers, and fibrinoid necrosis. This overloading of the tendon may eventually lead to irritation and tearing. Injury to the transverse humeral ligament can lead to medial dislocation or subluxation. Also, an osteochondroma in the bicipital groove has been reported to cause bicipital tendinitis in a baseball player by displacing the tendon. As tendinitis progresses there is a greater risk for rupture.
Clinical Presentation 1,6
Patients experience a throbbing ache that is deep in the anterior part of the shoulder. A tender bicipital groove upon palpation is a strong indication of biceps tendinitis or other biceps tendon injury. Patients will most likely experience pain with overhead activities. Pain may radiate to the deltoid muscle or hand, although the pain typically stays localized at the bicipital groove. Patients complain that their pain is worse at night so it is important to avoid lying on the shoulder that is painful. The pain is also worse when the shoulder functions against resistance. When biceps instability is involved, the patient may experience a clicking or popping sound in the anterior part of the shoulder with certain movements.
Evaluation/Special Orthopedic Tests 1,4
Yergason Test: The test in conducted with the patient’s arm by their side and flexed to 90 degrees. Next, the forearm is supinated against resistance. Pain indicates inflammation of the tendon of the long head of the biceps or a lesion of the glenoid labrum. Sensitivity of Yergason’s test is reported to be 43%, and 79% specificity.
Speed Test: The patient begins with their elbow fully extended, the arm fully supinated and in 30 degrees of flexion. The patient then attempts to further flex against the given resistance. Pain indicates inflammation of the tendon of the long head of the biceps or a lesion of the glenoid labrum. Sensitivity of Speed’s test is 32%, while specificity is 75%.
Indications for Surgery 7
Surgery is typically a last resort for patients suffering from biceps tendonitis. Indications for surgery include:
- A 25%-50% tear of the biceps tendon
-Type II SLAP tear in a patient older than 50 years who is symptomatic
-Type IV SLAP tear
-Chronic pain that has not subsided after 3 months of conservative therapy
-Failure of surgical decompression
-Subluxation from the bicipital groove
If conservative therapy is unsuccessful after 3 months, surgery is recommended. The two most common procedures are the biceps tenotomy and tenodesis. Both procedures have shown to be successful for patients suffering from biceps tendinopathy. “Tenotomy is the procedure of choice for patients 60 years and older with a ruptured biceps tendon, while tenodesis is a reasonable option for patients younger than 60 years , as well as active patients, athletes, manual laborers, and patients who object to a muscle bulge above the elbow.”
Conservative Treatment 1,8
The initial goals of treatment are to control inflammation and swelling. Ice and nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat pain and inflammation. Rest from aggravating activities such as throwing or other overhead motions is important. Bicipital tendinitis has shown improvement with stretching and the use of transcutaneous electrical nerve stimulation (TENS). Regaining complete shoulder range of motion and strength of the static and dynamic shoulder stabilizers is achieved through physical therapy. If pain is not relieved by conservative treatment, physicians sometimes recommend a local anesthetic injection.
Nonoperative and Postoperative Rehabilitation Protocols 5
For more information on the Non-operative and Postoperative Rehabilitation Protocols, please read this article - "Long Head of the Biceps Tendon Pain: Differential Diagnosis and Treatment" by Ryan J. Krupp, Mark A. Kevern, Michael D. Gaines, Stanley Kotara, Steven B. Singleton
Other Pathological Disorders Associated with Biceps Tendinitis 3,6
-Long Head of Biceps Tenosynovitis
-Rotator Cuff Tears/Tendinitis
-Superior Labrum Anterior Posterior (SLAP) Tears
-Transverse Humeral Ligament Injury
Addition Web Based Sources
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2. Elser F, Braun S, Dewing CB, Giphart JE, Millett PJ. Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon. Arthroscopy. 2011;27(4):581-592. doi: 10.1016/j.arthro.2010.10.014.
3. Friedman DJ, Dunn JC, Higgins LD, Warner JJ. Proximal biceps tendon: Injuries and management. Sports Med Arthrosc. 2008;16(3):162-169. doi: 10.1097/JSA.0b013e318184f549.
4. House J, Mooradian A. Evaluation and management of shoulder pain in primary care clinics. South Med J. 2010;103(11):1129-35; quiz 1136-7. doi: 10.1097/SMJ.0b013e3181f5e85f.
5. Krupp RJ, Kevern MA, Gaines MD, Kotara S, Singleton SB. Long head of the biceps tendon pain: Differential diagnosis and treatment. J Orthop Sports Phys Ther. 2009;39(2):55-70. doi: 10.2519/jospt.2009.2802.
6. Nho SJ, Strauss EJ, Lenart BA, et al. Long head of the biceps tendinopathy: Diagnosis and management. J Am Acad Orthop Surg. 2010;18(11):645-656.
7. Onga T, Yamamoto T, Akisue T, Marui T, Kurosaka M. Biceps tendinitis caused by an osteochondroma in the bicipital groove: A rare cause of shoulder pain in a baseball player. Clin Orthop Relat Res. 2005;(431)(431):241-244.
8. Durham B, Ho S. Bicipital tendonitis treatment and management. Medscape Website. Available at:http://emedicine.medscape.com/article/96521-treatment. Accessed December 1, 2011