Bicipital Tendonitis Workup

  • Author: Britt A Durham, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Feb 8, 2012
 

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.
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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]
  • Arthroscopy[20, 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.
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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.[23]
  • Ultrasonographic-guided percutaneous steroid injections have been described in the literature and may result in better placement with potentially less complications.
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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, California Medical Board District Medical Consultant, Lakewood Atheletic Sports Medicine Team Physician

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.

Specialty Editor Board

David T Bernhardt, MD  Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, 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 Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

References

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

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  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. Jul 6 2007;8:63. [Medline]. [Full Text].

  23. Mitra R, Nguyen A, Stevens KJ. Fluoroscopically guided supraglenoid tubercle steroid injections for the management of biceps tendonitis. Pain Pract. Jul-Aug 2011;11(4):392-6. [Medline].

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

 
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