History
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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.
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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.
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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.
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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. [12]
Physical
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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.
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Flexion of the elbow against resistance aggravates the patient's pain.
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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.
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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.
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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.
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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.
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Bicipital tendinitis with labral tears or rotator cuff tears may not improve if all the conditions are not treated.
Causes
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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. [13]
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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.
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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.
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Labral tears may disrupt the biceps anchor, resulting in dysfunction and causing pain.
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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. [14]
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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. [15]
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Biceps muscle and tendons.
