eMedicine Specialties > Sports Medicine > Upper Limb
Bicipital Tendonitis: Treatment & Medication
Updated: Jan 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
The initial goals of the acute phase of treatment for bicipital tendinitis are to reduce inflammation and swelling. Patients should restrict over-the-shoulder movements, reaching, and lifting.
Patients should apply ice to the affected area for 10-15 minutes, 2-3 times per day for the first 48 hours. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are used for 3-4 weeks to treat inflammation and pain. The degree of immobilization depends upon the degree of the injury and the patient's discomfort. Most authors agree that prolonged immobilization tends to result in a stiff shoulder.
Physical therapy plays a minor role in the treatment of acute bicipital tendinitis; however, some authors recommend daily weighted, pendulum stretch exercises for uncomplicated and mild cases of acute bicipital tendinitis. Use of transcutaneous electrical nerve stimulation (TENS) has been reported with some success.
Phonophoresis and iontophoresis are examples of methods that are used to deliver steroids into inflamed tissue without an injection. Phonophoresis uses ultrasound, whereas iontophoresis uses electrical repulsion to transport medicines through the skin. In order to deliver an effective steroid concentration, the target area should be superficial, and serial application is necessary.
Medical Issues/Complications
It is important to realize that performing analgesic and steroid injections into the bicipital groove is not without risk. Use care to avoid direct injection into the long head of the biceps tendon itself because this can result in direct trauma to — and may lead to atrophy and/or rupture of — the tendon. Other complications from injections include postinjection infection and inflammatory reaction. In order to exclude a possible missed differential diagnosis, radiographic imaging should be considered if no improvement occurs after treatment.
Consultations
Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.
Other Treatment
A local injection of an anesthetic and steroid can be given in the bicipital groove. A combination of 2-3 mL of anesthetic with 1 mL of methylprednisolone (Depo-Medrol; Pfizer Inc, New York, NY) is typically recommended 3-6 weeks after the acute injury. A repeat injection can be performed 4 weeks later if the symptoms have not decreased by 50%. Caution is indicated with additional injections or with patients older than 40 years because there is an increased risk of biceps tendon rupture from repetitive injections. Restrict lifting and overhead activities by the patient for 30 days after the injection.
Recovery Phase
Rehabilitation Program
Physical Therapy
Physical therapy and rehabilitation are directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint while restoring the affected shoulder's ROM, which is critical for most athletes.
The goal of the recovery phase is to achieve and maintain full and painless ROM. Weighted, pendulum stretch exercises are combined with isometric toning. These exercises are recommended 3 times per week throughout the recovery phase. Passive stretching with ROM exercises removes residual shoulder stiffness. The uninvolved shoulder can be used as a standard comparison to achieve symmetric ROM.
Occupational Therapy
Although a rehabilitation program should improve strength and flexibility, adding an interval program can help restore normal joint arthrokinematics. Interval tennis and baseball programs have been developed for highly competitive athletes as these individuals recover from bicipital tendinitis. The patient progresses in a series of steps and stages, with the goal of returning safely to competition without reinjury. The progression of therapy is dependent upon a gradual, painless increase in activity without excessive fatigue.
Medical Issues/Complications
Failure to recognize concomitant injuries with bicipital tendinitis could result in delayed healing and damage from inappropriate treatment. Physical therapy for shoulder injuries or a misdiagnosed injury may aggravate other conditions in the elbow and neck.
Consultations
Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.
Other Treatment (Injection, manipulation, etc.)
Weighted, pendulum swings should begin with moist heat application to the shoulder on the affected side, followed by therapy with 5- to 10-lb weights, which are held lightly in the hand. The shoulder muscle should be relaxed and the arm kept vertical and close to the body. The arm is allowed to swing back and forth, no greater than 1 inch in any direction. Note: This exercise is not appropriate for patients who have shoulder separation or strain, upper back strain, or neck strain.
Maintenance Phase
Rehabilitation Program
Physical Therapy
The maintenance phase concentrates on the patient developing increased strength and endurance on the affected side. This phase can begin as soon as patient discomfort is effectively controlled and should continue for at least 3 weeks after the pain has completely resolved. When performing strengthening exercises, it is safer for the individual to start out with low tension, followed by a gradual increase in force, because flare-ups can occur.
The patient continues isotonic and isokinetic stretching and is allowed limited participation in sports activities. Monitor the patient and adjust his/her activities as progress allows. Note: Conditioning and proper throwing techniques are important for certain athletes because improper mechanics may result in tissue fatigue and damage.
Surgical Intervention
Surgical intervention is not recommended for bicipital tendinitis if the patient is making a slow and gradual improvement. Surgical treatment is only indicated after a 6-month trial of conservative care is unsuccessful. Although good results have been reported with arthroscopic decompression, acromioplasty with anterior acromionectomy is the standard surgical treatment for bicipital tendinitis. The biceps tendon does not generally undergo tenodesis unless severe attritional wear or eminent rupture is found.7,16 No attempt is made to repair biceps tendon ruptures older than 6 weeks.
Tenodesis is not recommended when it is believed that the tendinitis is reversible. Specific indications for tenodesis of the biceps long head include the following7,16 :
- Greater than 25% partial-thickness biceps tendon tear
- Severe subluxation from the bicipital groove
- Disruption of the associated bony or ligamentous anatomy of the groove itself
- Biceps tendon atrophy greater than 25%
- Failure of surgical decompression
Growing evidence has shown a shift from routine tenodesis to a more individual approach, with considerations such as physiologic age, activity level, expectations, and specific combinations of shoulder pathology as important factors.7 Although new repair techniques continue to be developed, the preference is for preservation of the biceps-labral complex rather than routine surgery. When surgery is performed for bicipital tendinitis, the procedure is typically performed through an open anterior incision. Variations of this surgery include arthroscopic techniques and open exposures with suture anchors through the subclavian portal.
Consultations
Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.
Medication
The goals of pharmacotherapy are to reduce patient morbidity and prevent complications.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs are anti-inflammatory and non-narcotic medications that have analgesic and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions. The treatment of pain tends to be patient specific.
Ibuprofen (Ibuprin, Advil, Motrin)
DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-800 mg PO tid/qid
Pediatric
<12 years: Not indicated
>12 years: 20-40 mg/kg/d PO divided tid/qid
Concomitant use with anticoagulants may potentiate anticoagulant effects; effects of oral diabetic hypoglycemic agents may be potentiated with combination use with ibuprofen, leading to hypoglycemia; may decrease the clearance and absorption of methotrexate, lithium, diuretics, and antihypotensives
Documented hypersensitivity to ibuprofen, other NSAIDs, or aspirin; avoid in patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Local anesthetics
Local anesthetics block the generation of conduction impulses in a nerve, thereby preventing the transmission of pain.
Bupivacaine (Sensorcaine, Marcaine)
An amide-type local anesthetic that shares similar properties with other drugs in this classification, including lidocaine (Xylocaine; AstraZeneca, Mississauga, Ontario, Canada). Has the advantage of a longer duration of anesthesia.
Administer the smallest dose and concentration that is required to produce the desired results. Dose varies with the anesthetic procedure, the area to be anesthetized, the vascularity of the tissues, and individual tolerance.
Adult
Local anesthesia: 5-10 mL (0.25% sol) 12.5-25 mg; not to exceed 2.5 g/kg
Pediatric
<12 years: Not recommended
>12 years: Administer as adults
May enhance the effects of CNS depressants; coadministration may increase the toxicity of MAOIs, TCAs, beta-blockers, vasopressors, and phenothiazines; have anti-arrhythmic effects, which may cause additive toxicity interactions with phenytoin, procainamide, propranolol, and quinidine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Systemic absorption produces cardiovascular and CNS effects; rate of absorption is dependent upon the dose, rate of administration, and vascularity of the injection site; aspirate for blood before injection to avoid accidental intravenous administration; adverse reactions include restlessness, anxiety, dizziness, blurred vision, tremors, confusion, seizure, hypotension, palpitations, and syncope; consider reduced dose in patients who have lowered hepatic clearance from disease or age
Glucocorticoids
Glucocorticoids stimulate synthesis of enzymes that decrease inflammatory responses and suppress the immune system.
Methylprednisolone acetate (Depo-Medrol)
Methylprednisolone is a potent, intermediate-acting glucocorticoid, which has no mineralocorticoid activity. A useful anti-inflammatory and immunosuppressant agent.
Adult
4-80 mg/d intra-articular, intrasynovial, intrabursal, intralesional, or soft-tissue injection
Pediatric
140-835 mcg/kg/d intra-articular, intrasynovial, intrabursal, intralesional, or soft-tissue injection
Glucocorticoids may decrease the effects of PO anticoagulants, isoniazid, insulin, PO hypoglycemic agents, and salicylates
Documented hypersensitivity to ingredients of adrenocorticoid preparations; systemic fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with hypertension, diabetes mellitus, tuberculosis, psychiatric disorders, glaucoma, and gastric ulcers; glucocorticoids suppress the immune system, which may result in complications in patients receiving live vaccines and in patients with concomitant infectious disease
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
Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. Aug 2007;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.
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].
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].
Patton WC, McCluskey GM 3rd. Biceps tendinitis and subluxation. Clin Sports Med. Jul 2001;20(3):505-29. [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. Mar 2004;20(3):231-6. [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. Feb 2005;431:241-4. [Medline].
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].
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].
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].
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].
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;8:63. [Medline]. [Full Text].
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].
Ellenbecker TS. Rehabilitation of shoulder and elbow injuries in tennis players. Clin Sports Med. Jan 1995;14(1):87-110. [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. Dec 2007;15(12):1478-81. [Medline].
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].
Murtagh J. Bicipital tendinitis. Aust Fam Physician. Jun 1991;20(6):817. [Medline].
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].
van Tulder M, Malmivaara A, Koes B. Repetitive strain injury. Lancet. May 26 2007;369(9575):1815-22. [Medline].
Further Reading
Keywords
bicipital tendinitis, biceps tendinitis/tendonitis, attrition tendinitis/tendonitis of the biceps
