eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions
Biceps Tendinopathy
Updated: Nov 14, 2008
Introduction
Background
Biceps tendinopathy describes pain and tenderness in the region of the biceps tendon. The biceps musculotendinous junction is particularly susceptible to overuse injuries, especially in individuals performing repetitive lifting activities.1 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.2
Related eMedicine topics:
Bicipital Tendon Injuries
Bicipital Tendonitis
Elbow and Forearm Overuse Injuries
Shoulder Impingement Syndrome
Pathophysiology
Historically, all disorders of the biceps tendon have been termed biceps tendinitis. Evidence suggests that degenerative changes in the tendon occur without inflammation. In acute cases, an inflammatory pathology may still be a valid explanation of biceps tendon pain.3
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).4 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 follows4 :
- 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.
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).5
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 eMedicine topic:
Tenosynovitis
Frequency
United States
Biceps tendinopathy is a common condition, but the exact frequency is unknown.
Clinical
History
The diagnosis of biceps tendinopathy is primarily clinical.6,7 Patient history suggests the diagnosis. Characteristics of the condition are as follows:
- Pain is reported in the region of the anterior shoulder located over the bicipital groove, occasionally radiating down to the elbow.
- The pain is aggravated by activities that require shoulder flexion, forearm supination, and/or elbow flexion.
- Pain is usually exacerbated by the initiation of activity.
- Some patients describe fatigue with shoulder movements.
- The symptoms are alleviated by rest, ice, massage, stretching, and sometimes heat.
- Night pain is not uncommon.
Physical
Physical examination for biceps tendinopathy includes the following:
- Inspection - Muscle bulk of the shoulder girdle, anatomical abnormalities, posture
- Palpation - For tenderness over the biceps tendon in the bicipital groove; compare side to side (because there is often tenderness in asymptomatic patients)
- Range of motion (ROM) - Passive and active ROM of the shoulder in forward flexion, extension, abduction, adduction, internal and external rotation
- Neurologic testing - Muscle strength, sensation, and deep tendon reflexes; strength testing possibly limited by pain
- Special biceps tests
- Speed test 1 - With the forearm in the supinated position and the elbow fully extended, the patient attempts to flex the arm (forward flexion at the shoulder) against the resistance provided by the examiner. Tenderness in the bicipital groove is considered a positive test result and is indicative of bicipital tendinitis.
- Speed test 2 - This test is a variation on Speed test 1. Test 2 may be performed by having the patient forward-flex the arm to 90 º while the examiner tries to move the patient's arm into extension against resistance provided by the patient. A positive test result is indicated by discomfort or pain in the bicipital groove.
- Yergason test - The patient's elbow is flexed to 90 º and is stabilized against the thoracic cage, with the forearm pronated; the examiner resists supination while the patient also laterally rotates the arm against resistance. The test is considered positive if the patient experiences discomfort or pain in the bicipital groove or if the tendon pops out of the groove.
- Gilchrist test - The patient lifts a 5-pound weight overhead with an externally rotated arm and slowly lowers it to the lateral horizontal position. Discomfort or pain in the bicipital groove is considered a positive test result.
- Lippman test - With the patient's arm flexed to 90 º, the examiner palpates the biceps tendon 3 inches (7.6 cm) below the glenohumeral joint and moves the biceps tendon from side to side. Pain and a palpable displacement of the tendon from its groove indicate tenosynovitis with instability of the biceps tendon.
- Other tests - Tests for associated rotator cuff, labral, and acromioclavicular joint pathology are as follows:
- Impingement tests include the Hawkins-Kennedy test and the Neer test.
- Acromioclavicular joint tests include the cross-body adduction test.
- Labral tests include the O'Brien test, the anterior slide test, and the Clunk test.
Causes
Biceps tendinopathy can result from the following causes:
- Poor lifting techniques
- Chronic, repetitive upper extremity activities (shoulder/elbow flexion)
- Impingement syndrome
- Rotator cuff pathology
- Biceps subluxation
- Shoulder girdle muscle imbalances
- Poor posture
- Overload (usually eccentrically)
- Lack of flexibility/capsular tightness
- Direct trauma
- Multidirectional shoulder instability
- Calcifications of the tendon
- Osteoarthritis and spurring
- Anatomical abnormalities (eg, variations of the bicipital groove, fractures, first rib subluxations)
More on Biceps Tendinopathy |
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| Treatment & Medication: Biceps Tendinopathy |
| Follow-up: Biceps Tendinopathy |
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| References |
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Further Reading
Keywords
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