eMedicine Specialties > Sports Medicine > Upper Limb

Bicipital Tendonitis: Differential Diagnoses & Workup

Author: Britt A Durham, MD, Director of Risk Management, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center and University of California at Los Angeles; CFO of 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: Jan 4, 2008

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]

Related Medscape topic:
Resource Center Arthritis 

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.
    • 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.10,11
    • 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.12
  • Arthroscopy13,14
    • 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.15
  • Judicious use of subacromial and/or glenohumeral joint steroid injections are recommended for persistent cases of bicipital tendinitis.1,15 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
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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. 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].

  6. 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].

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

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. 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].

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

  15. 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].

  16. 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].

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

  18. 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].

  19. Longo UG, Franceschi F, Ruzzini L, et al. Characteristics at haematoxylin and eosin staining of ruptures of the long head of the biceps tendon. Br J Sports Med. Dec 10 2007;Epub ahead of print. [Medline].

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

  21. Shiri R, Varonen H, Heliövaara M, Viikari-Juntura E. Hand dominance in upper extremity musculoskeletal disorders. J Rheumatol. May 2007;34(5):1076-82. [Medline].

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

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Further Reading

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Keywords

bicipital tendinitis, biceps tendinitis/tendonitis, attrition tendinitis/tendonitis of the biceps

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Contributor Information and Disclosures

Author

Britt A Durham, MD, Director of Risk Management, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center and University of California at Los Angeles; CFO of 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: Nothing to disclose.

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.

 
 
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