eMedicine Specialties > Sports Medicine > Upper Limb

Bicipital Tendonitis: Differential Diagnoses & Workup

Author: Britt A Durham, MD, Director of Risk Management, Department of Emergency Medicine, Martin Luther King Medical and Trauma Center, King-Drew Medical Center; Assistant Professor of Emergency Medicine, Drew College of Medicine; Assistant Clinical Professor of Emergency Medicine, UCLA School of Medicine; Partner and Chief Financial Officer, Durcress Medical Group
Coauthor(s): Richard Chambers, MD, Chief of Orthopedic, Diabetes and Amputee Service, Clinical Associate Professor, Department of Orthopedic Surgery, Rancho Los Amigos Medical Center, University of Southern California
Contributor Information and Disclosures

Updated: Dec 15, 2009

Differential Diagnoses

Superior Labrum Lesions

Other Problems to Be Considered

Fracture of the greater or lesser tuberosity
Glenohumeral instability (humeral subluxation)
Glenoid labrum tear
Inflammatory arthropathy
Neoplasm
Peripheral nerve entrapment
Strain and tear of the subscapularis
Synovitis

See also the following on eMedicine:
Adhesive Capsulitis [in the Orthopedic Surgery section]
Adhesive Capsulitis [in the Physical Medicine and Rehabilitation section]
Bursitis [in the Orthopedic Surgery section]
Bursitis [in the Emergency Medicine section]
Multidirectional Glenohumeral Instability
Nerve Entrapment Syndromes [in the Neurology section]
Nerve Entrapment Syndromes of the Lower Extremity [in the Orthopedic Surgery section]
Peripheral Nerve Injuries
Posterior Glenohumeral Instability
Rotator Cuff Disease Superior Labral Lesions [in the Orthopedic Surgery section]

Workup

Laboratory Studies

  • Laboratory tests are usually not indicated in cases of bicipital tendinitis, except when considering systemic diseases in the differential diagnosis or when excluding the possibility of neoplasm.

Imaging Studies

  • Radiographs
    • Standard shoulder radiographs are generally not helpful or necessary in cases of isolated bicipital tendinitis.
    • Plain radiographs with bicipital groove views may demonstrate calcifications in the groove; however, calcifications rarely alter treatment.
    • Radiographic studies of the neck and elbow may be necessary to exclude referred shoulder pain from these locations.
    • Radiographs are indicated in cases that are not isolated, do not respond to treatment, or in patients in which there is the clinical suspicion of or a history of neoplastic disease.
    • Subacromial spurring is often seen in impingement syndrome and is most visible on the outlet and anteroposterior impingement syndrome radiographic views.
  • Magnetic resonance imaging (MRI)
    • This imaging study can demonstrate the entire course of the long head of the biceps tendon. However, MRI is expensive and not cost effective as a routine imaging test for bicipital lesions.15,16 Buck et al attempted to correlate alterations in biceps tendon diameter and signal on MRIs to gross anatomy and histology with the use of cadaveric shoulder specimens.16 Two independent readers assessed T1-weighted, T2-weighted fat-saturated, and proton density-weighted fat-saturated spin-echo sequences in a blinded fashion. The investigators found that MRI-based localization of degeneration correlated well with histologic findings, but although diameter changes were specific in diagnosing biceps tendinopathy, they were not sensitive.16 In another study, Gaskin et al retrospectively evaluated medical records with prospective MRI diagnoses of tendinopathy and/or partial tears of the long head of the biceps tendon at the entrance of the bicipital groove, with surgical correlation within 4 months of the imaging.15 Tears at this location are generally difficult to detect on MRI.One hundred percent (16 of 16) of patients demonstrated focal tendon intrasubstance signal abnormalities, whereas 50% showed focal tendon enlargement (8 of 16). Ninety-four percent (15 of 16) of the biceps partial tears received surgical treatment. Gaskin et al suggested that although focal partial tears of the biceps tendon may coexist with other causes of shoulder pain, they may also exist in isolation and can be treated surgically.15
    • MRI should be considered after unsuccessful rehabilitation and in cases of suspected rotator cuff injury or labral tear injury.
  • Ultrasound and arthrography
    • Some authors have described the use of ultrasound and arthrography to identify tendon lesions.17,18
    • Although ultrasound has the most variable results because it is operator dependent, newer technologies have resulted in improved visualization of the calcific deposits, edema, and tendon displacement that are often associated with bicipital tendinitis.19
  • Arthroscopy20,21
    • Arthroscopy may be useful in evaluating chronic shoulder pain.
    • This procedure is sensitive for detecting and differentiating subtle defects in the shoulder, including lesions in the superior labral complex and the articular surface of the humeral head.
    • Arthroscopy should not be used as a diagnostic tool for bicipital tendinitis unless the patient is not responding to the usual effective treatment or if other lesions or diagnoses are considered. Arthroscopy evaluates the intra-articular portion of the long head of the biceps tendon and is generally not performed for diagnosis alone.
    • Arthroscopy is usually indicated when lesions of the biceps tendon occur with other diagnoses, such as tears of the labrum or rotator cuff and/or with intra-articular loose bodies.

Procedures

  • Although not routinely used, a local anesthetic block in the bicipital groove may help the clinician to differentiate bicipital tendinitis from referred rotator cuff pain and glenohumeral joint disease. Use of steroids during this procedure can have long-term treatment value.22
  • Judicious use of subacromial and/or glenohumeral joint steroid injections are recommended for persistent cases of bicipital tendinitis.1,22 Note: Although injection into the biceps sheath is effective, injection into the tendon itself can result in biceps tendon degeneration and rupture.
  • Ultrasonographic-guided percutaneous steroid injections have been described in the literature and may result in better placement with potentially less complications.

More on Bicipital Tendonitis

Overview: Bicipital Tendonitis
Differential Diagnoses & Workup: Bicipital Tendonitis
Treatment & Medication: Bicipital Tendonitis
Follow-up: Bicipital Tendonitis
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. Aug 2007;89(8):1001-9. [Medline].

  2. Safran MR, McKaeg DB, Van Camp SP, eds. Biceps tendon injuries. Manual of Sports Medicine. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998:347-9.

  3. Nicholis JA, Hershman EB, eds. Bicipital tendinitis. The Upper Extremity in Sports Medicine. 2nd ed. St. Louis, Mo: Mosby; 1995:303-6.

  4. Rockwood CA Jr, Matsen FA II, eds. The Shoulder. Philadelphia, Pa: WB Saunders; 1990:810-21.

  5. Murtagh J. Bicipital tendinitis. Aust Fam Physician. Jun 1991;20(6):817. [Medline].

  6. 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. Nov-Dec 2008;17(6):898-904. [Medline].

  7. Patton WC, McCluskey GM 3rd. Biceps tendinitis and subluxation. Clin Sports Med. Jul 2001;20(3):505-29. [Medline].

  8. Ellenbecker TS. Rehabilitation of shoulder and elbow injuries in tennis players. Clin Sports Med. Jan 1995;14(1):87-110. [Medline].

  9. Ouellette H, Labis J, Bredella M, et al. Spectrum of shoulder injuries in the baseball pitcher. Skeletal Radiol. Oct 3 2007;Epub ahead of print. [Medline].

  10. Park SS, Loebenberg ML, Rokito AS, Zuckerman JD. The shoulder in baseball pitching: biomechanics and related injuries -- part 1. Bull Hosp Jt Dis. 2002-2003;61(1-2):68-79. [Medline]. [Full Text].

  11. 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. May 2009;27(7):711-7. [Medline].

  12. 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. Dec 2007;15(12):1478-81. [Medline].

  13. Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. Sep 1 2009;80(5):470-6. [Medline].

  14. 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. Feb 2005;431:241-4. [Medline].

  15. 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. Oct 2009;38(10):959-65. [Medline].

  16. 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. Nov 2009;193(5):1367-75. [Medline].

  17. Papatheodorou A, Ellinas P, Takis F, et al. US of the shoulder: rotator cuff and non-rotator cuff disorders. Radiographics. Jan-Feb 2006;26(1):e23. [Medline]. [Full Text].

  18. Lecoq B, Levasseur R, Fournier L, Schmutz G, Marcelli C. Atypical pattern of acute severe shoulder pain: contribution of sonography. Joint Bone Spine. Nov 2004;71(6):592-4. [Medline].

  19. Ardic F, Kahraman Y, Kacar M, et al. Shoulder impingement syndrome: relationships between clinical, functional, and radiologic findings. Am J Phys Med Rehabil. Jan 2006;85(1):53-60. [Medline].

  20. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford). May 2006;45(5):508-21. [Medline]. [Full Text].

  21. Ellman H, Gartsman GM. Arthroscopic Shoulder Surgery and Related Procedures. Philadelphia, Pa: Lea & Febiger; 1993:243-4.

  22. 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;8:63. [Medline]. [Full Text].

  23. Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg. Nov-Dec 1999;8(6):644-54. [Medline].

  24. Friedman DJ, Dunn JC, Higgins LD, Warner JJ. Proximal biceps tendon: injuries and management. Sports Med Arthrosc. Sep 2008;16(3):162-9. [Medline].

  25. 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. Mar 2004;20(3):231-6. [Medline].

  26. Shah RR, Haghpanah S, Elovic EP, Flanagan SR, Behnegar A, Nguyen V, et al. MRI findings in the painful poststroke shoulder. Stroke. Jun 2008;39(6):1808-13. [Medline].

  27. van Tulder M, Malmivaara A, Koes B. Repetitive strain injury. Lancet. May 26 2007;369(9575):1815-22. [Medline].

[ CLOSE WINDOW ]

Further Reading

Related eMedicine Topics

Clinical Trials

Clinical Guidelines

[ CLOSE WINDOW ]

Keywords

bicipital tendonitis, bicipital tendinitis, biceps tendinitis, biceps tendonitis, attrition tendinitis of the biceps, attrition tendonitis of the biceps, rotator cuff, tennis elbow, golfer's elbow

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Britt A Durham, MD, Director of Risk Management, Department of Emergency Medicine, Martin Luther King Medical and Trauma Center, King-Drew Medical Center; Assistant Professor of Emergency Medicine, Drew College of Medicine; Assistant Clinical Professor of Emergency Medicine, UCLA School of Medicine; Partner and Chief Financial Officer, Durcress Medical Group
Britt A Durham, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Richard Chambers, MD, Chief of Orthopedic, Diabetes and Amputee Service, Clinical Associate Professor, Department of Orthopedic Surgery, Rancho Los Amigos Medical Center, University of Southern California
Richard Chambers, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Diabetes Association, American Orthopaedic Foot and Ankle Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin
David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.