Bicipital Tendonitis Clinical Presentation
- Author: Britt A Durham, MD; Chief Editor: Sherwin SW Ho, MD more...
See the list below:
- Patients typically complain of achy anterior shoulder pain, which is exacerbated by lifting or elevated pushing or pulling. A typical complaint is pain with overhead activity or with lifting heavy objects.
- Pain may be localized in a vertical line along the anterior humerus, which worsens with movement. Often, however, the location of the pain is vague, and symptoms may improve with rest.
- Most patients with bicipital tendinitis have not sustained an acute traumatic injury. However, partial traumatic biceps tendon ruptures have been described and may occur in combination with underlying tendinitis. Individuals with rupture of the long head of the biceps tendon may report a sudden and painful popping sensation. The retracted muscle belly bulges over the anterior upper arm, which is commonly described as the "Popeye" deformity. In patients without acute traumatic injuries, the biceps tendon rupture is usually preceded by a history of shoulder pain that quickly resolves after a painful audible snap occurs.
- Occasionally, shoulder instability and subluxation can be associated with biceps degeneration from chronic tendinitis, resulting in a palpable snap in a painful arc of motion that is seen in throwing athletes. Superior labral tears (superior labrum anterior and posterior [SLAP] lesions) may have similar findings, but these injuries are more prone to locking or catching symptoms.
See the list below:
- Local tenderness is usually present over the bicipital groove, which is typically located 3 inches below the anterior acromion. The tenderness may be localized best with the arm in 10 º of external rotation.
- Flexion of the elbow against resistance aggravates the patient's pain.
- Passive abduction of the arm in an arc maneuver may elicit pain that is typical of impingement syndrome; however, this finding may be negative in cases of isolated bicipital tendinitis.
- Speed test: The patient complains of anterior shoulder pain with flexion of the shoulder against resistance, while the elbow is extended and the forearm is supinated.
- Yergason test: The patient complains of pain and tenderness over the bicipital groove with forearm supination against resistance, with the elbow flexed and the shoulder in adduction. Popping of subluxation of the biceps tendon may be demonstrated with this maneuver.
- The remainder of the examination should include evaluation and documentation of active and passive range of motion (ROM) and joint stability in order to assess the rotator cuff and glenoid labrum. A complete evaluation includes a complete neurovascular assessment.
- Bicipital tendinitis with labral tears or rotator cuff tears may not improve if all the conditions are not treated.
See the list below:
- The long head of the biceps tendon passes down the bicipital groove in a fibrous sheath between the subscapularis and supraspinatus tendons. This relationship causes the biceps tendon to undergo degenerative and attritional changes that are associated with rotator cuff disease because the biceps tendon shares the associated inflammatory process within the suprahumeral joint.
- Full humeral head abduction places the attachment area of the rotator cuff and biceps tendon under the acromion. External rotation of the humerus at or above the horizontal level compresses these suprahumeral structures into the anterior acromion. Repeated irritation leads to inflammation, edema, microscopic tearing, and degenerative changes.
- In younger athletes, relative instability due to hyperlaxity may cause similar inflammatory changes on the biceps tendon due to excessive motion of the humeral head.
- Labral tears may disrupt the biceps anchor, resulting in dysfunction and causing pain.
- The transverse humeral ligament holds the biceps tendon long head within the bicipital groove. Injuries and disruption of the ligament can lead to subluxation and medial dislocation of the biceps tendon. Local edema and calcifications can physically displace the biceps tendon from the bicipital groove, resulting in subluxation. An osteochondroma in the bicipital groove has been reported as a cause of bicipital tendinitis in a baseball player by physical displacement and subluxation.
- A study evaluated the histologic findings of the extra-articular portion of the long head of the biceps (LHB) tendon and synovial sheath in order to compare those findings to known histologic changes seen in other tendinopathies. The study concluded that anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases. The histologic findings of the extra-articular portion of the LHB tendon and synovial sheath are similar to the pathologic findings in de Quervain tenosynovitis at the wrist, and may be due to a chronic degenerative process similar to this and other tendinopathies of the body.
Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007 Aug. 89(8):1001-9. [Medline].
Safran MR, McKaeg DB, Van Camp SP, eds. Biceps tendon injuries. Manual of Sports Medicine. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998. 347-9.
Nicholis JA, Hershman EB, eds. Bicipital tendinitis. The Upper Extremity in Sports Medicine. 2nd ed. St. Louis, Mo: Mosby; 1995. 303-6.
Rockwood CA Jr, Matsen FA II, eds. The Shoulder. Philadelphia, Pa: WB Saunders; 1990. 810-21.
Murtagh J. Bicipital tendinitis. Aust Fam Physician. 1991 Jun. 20(6):817. [Medline].
Singaraju VM, Kang RW, Yanke AB, McNickle AG, Lewis PB, Wang VM, et al. Biceps tendinitis in chronic rotator cuff tears: a histologic perspective. J Shoulder Elbow Surg. 2008 Nov-Dec. 17(6):898-904. [Medline].
Patton WC, McCluskey GM 3rd. Biceps tendinitis and subluxation. Clin Sports Med. 2001 Jul. 20(3):505-29. [Medline].
Ellenbecker TS. Rehabilitation of shoulder and elbow injuries in tennis players. Clin Sports Med. 1995 Jan. 14(1):87-110. [Medline].
Ouellette H, Labis J, Bredella M, et al. Spectrum of shoulder injuries in the baseball pitcher. Skeletal Radiol. 2007 Oct 3. Epub ahead of print. [Medline].
Hadala M, Barrios C. Sports injuries in an America's Cup yachting crew: A 4-year epidemiological study covering the 2007 challenge. J Sports Sci. 2009 May. 27(7):711-7. [Medline].
Kim KC, Rhee KJ, Shin HD, Kim YM. A SLAP lesion associated with calcific tendinitis of the long head of the biceps brachii at its origin. Knee Surg Sports Traumatol Arthrosc. 2007 Dec. 15(12):1478-81. [Medline].
Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 2009 Sep 1. 80(5):470-6. [Medline].
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 Feb. 431:241-4. [Medline].
Streit JJ, Shishani Y, Rodgers M, Gobezie R. Tendinopathy of the long head of the biceps tendon: histopathologic analysis of the extra-articular biceps tendon and tenosynovium. Open Access J Sports Med. 2015. 6:63-70. [Medline].
Gaskin CM, Anderson MW, Choudhri A, Diduch DR. Focal partial tears of the long head of the biceps brachii tendon at the entrance to the bicipital groove: MR imaging findings, surgical correlation, and clinical significance. Skeletal Radiol. 2009 Oct. 38(10):959-65. [Medline].
Buck FM, Grehn H, Hilbe M, et al. Degeneration of the long biceps tendon: comparison of MRI with gross anatomy and histology. AJR Am J Roentgenol. 2009 Nov. 193(5):1367-75. [Medline].
Carr RM, Shishani Y, Gobezie R. How Accurate Are We in Detecting Biceps Tendinopathy?. Clin Sports Med. 2016 Jan. 35 (1):47-55. [Medline].
Lecoq B, Levasseur R, Fournier L, Schmutz G, Marcelli C. Atypical pattern of acute severe shoulder pain: contribution of sonography. Joint Bone Spine. 2004 Nov. 71(6):592-4. [Medline].
Ardic F, Kahraman Y, Kacar M, et al. Shoulder impingement syndrome: relationships between clinical, functional, and radiologic findings. Am J Phys Med Rehabil. 2006 Jan. 85(1):53-60. [Medline].
Ellman H, Gartsman GM. Arthroscopic Shoulder Surgery and Related Procedures. Philadelphia, Pa: Lea & Febiger; 1993. 243-4.
Skedros JG, Hunt KJ, Pitts TC. Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians. BMC Musculoskelet Disord. 2007 Jul 6. 8:63. [Medline]. [Full Text].
Mitra R, Nguyen A, Stevens KJ. Fluoroscopically guided supraglenoid tubercle steroid injections for the management of biceps tendonitis. Pain Pract. 2011 Jul-Aug. 11(4):392-6. [Medline].
Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg. 1999 Nov-Dec. 8(6):644-54. [Medline].
Scully WF, Wilson DJ, Grassbaugh JA, Branstetter JG, Marchant BG, Arrington ED. A simple surgical technique for subpectoral biceps tenodesis using a double-loaded suture anchor. Arthrosc Tech. 2013 May. 2(2):e191-6. [Medline]. [Full Text].
Friedman DJ, Dunn JC, Higgins LD, Warner JJ. Proximal biceps tendon: injuries and management. Sports Med Arthrosc. 2008 Sep. 16(3):162-9. [Medline].
Holtby R, Razmjou H. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. 2004 Mar. 20(3):231-6. [Medline].
van Tulder M, Malmivaara A, Koes B. Repetitive strain injury. Lancet. 2007 May 26. 369(9575):1815-22. [Medline].