Biceps Tendinopathy

Updated: Jul 20, 2017
  • Author: Peter Gonzalez, MD; Chief Editor: Robert H Meier, III, MD  more...
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Overview

Background

Biceps tendinopathy describes pain and tenderness in the region of the biceps tendon. [1] The biceps musculotendinous junction is particularly susceptible to overuse injuries, especially in individuals performing repetitive lifting activities. [2] This condition is often diagnosed incorrectly and confused with rotator cuff tendinopathy. Biceps tendinopathy is rarely seen in isolation. It coexists with other pathologies of the shoulder, including rotator cuff tendinopathy and tears, shoulder instability, and imbalances of the dynamic stabilizers. Among patients with biceps tendinopathy, 95% have "impingement syndrome" as their primary diagnosis. [3]

Related Medscape Reference topics:

Bicipital Tendon Injuries

Bicipital Tendonitis

Elbow and Forearm Overuse Injuries

Shoulder Impingement Syndrome

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Pathophysiology

Historically, all disorders of the biceps tendon have been termed biceps tendinitis. Evidence suggests that degenerative changes in the tendon occur without inflammation. [4]  A study by Streit et al supports the idea that inflammation is lacking in biceps tendinopathy. The study involved 26 patients who underwent surgery for anterior shoulder pain localized to the bicipital groove; histologic analysis of the extra-articular portion of the long head of the biceps tendon and synovial sheath showed chronic inflammation in just two of the patients and acute inflammation in none. Evaluation of the tendon and synovial sheath, however, suggested that a chronic degenerative process might be taking place in the subjects. [5]

In acute cases of biceps tendinopathy, an inflammatory pathology may still be a valid explanation of biceps tendon pain. [4]

Tendinitis describes inflammation of the tendon and the paratendon. This is usually caused by chronic overload, which leads to microscopic tears in the tendon, triggering an inflammatory response. Peritendinitis is the inflammation of the paratendon or tendon sheath. This usually occurs as a result of a direct injury or irritation in which the tendon rubs over a bony prominence; this is referred to as a tenosynovitis. Tendinosis is a histological definition describing degenerative changes in the tendon.

Macroscopic evaluation of a degenerative tendon reveals disorganized tissue that is soft and yellow or brown (mucoid degeneration). [6] The microscopic appearance reveals degenerative changes to collagen with fibrosis. Inflammatory mediators are not usually present in tendinosis. Most injuries of more than 3 months involve only a minimal amount of persistent inflammation, with tendinosis being a greater component of the injury.

The term tendinopathy refers to the clinical presentation of a symptomatic tendon. The underlying pathology, degenerative or inflammatory, is not considered in this definition.

Three etiologies of tendinopathy have been described, as follows [6] :

  • Mechanical theory - This theory states that repetitive loading of the tendon results in microscopic degeneration. Fibroplasia occurs within the tendon, resulting in scar tissue.
  • Vascular theory - According to this theory, tendon degeneration occurs as a result of focal areas of vascular compromise.
  • Neural modulation - The newest of the 3 theories, this focuses on the assumption that tendinopathy results from neurally mediated mast cell degranulation and the release of substance P.

More studies are needed to more clearly understand the relationship between the peripheral nervous system and tendinopathies.

Knowing the anatomy of the biceps brachii muscle is important in understanding biceps tendinopathy. The biceps brachii has 2 heads. The short head arises from the tip of the coracoid process of the scapula. The long head arises from the supraglenoid tubercle of the scapula, and the superior labrum runs through the intertubercular groove between the greater and lesser tubercles of the humerus. Proximally, the long head of the biceps acts as a shoulder stabilizer through depression of the humeral head. [7, 8]

The 2 heads join together in the distal arm to form 1 strong tendon, which inserts on the radial tuberosity on the upper end of the radius. Distally, the tendon gives off the bicipital aponeurosis (an expansion that blends with the flexor forearm muscles, extending to the ulna). The biceps brachii is innervated by the musculocutaneous nerve (C5, C6). [9, 10]

The actions of the biceps brachii muscle are flexion of the elbow, supination of the forearm, humeral head depression, and shoulder flexion (short head primarily).

Related Medscape Reference topic:

Tenosynovitis

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Epidemiology

Frequency

United States

Biceps tendinopathy is a common condition, but the exact frequency is unknown.

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