Bicipital Tendonitis

Bicipital tendinitis, or biceps tendinitis, is an inflammatory process of the long head of the biceps tendon and is a common cause of shoulder pain due to its position and function.[1, 2, 3, 4, 533] The tendon is exposed on the anterior shoulder as it passes through the humeral bicipital groove and inserts onto the superior aspect of the labrum of the glenohumeral joint. Disorders of the biceps tendon can result from impingement or as an isolated inflammatory injury. Other causes are secondary to compensation for rotator cuff disorders, labral tears, and intra-articular pathology.

For patient education resources, see the Arthritis Center and Sports Injury Center, as well as Tendinitis, Rotator Cuff Injury, and Repetitive Motion Injuries.

Frequency

United States

Bicipital tendinitis is frequently diagnosed in association with rotator cuff disease as a component of the impingement syndrome or secondary to intra-articular pathology, such as labral tears.[6]

As its name implies, the biceps has 2 proximal heads with a common distal insertion onto the radius. The long head of the biceps merges with the short head of the biceps to form the body of the biceps brachii muscle. This muscle is a powerful supinator and flexor of the forearm.

The long head biceps tendon lies in the bicipital groove of the humerus between the greater and lesser tuberosities and angles 90° inward at the upper end of the groove, crossing the humeral head to insert at the upper edge of the glenoid labrum and supraglenoid tubercle. The long head of the biceps tendon helps to stabilize the humeral head, especially during abduction and external rotation.

See the image below.

Biceps muscle and tendons.

Bicipital tendinitis frequently occurs from overuse syndromes of the shoulder,[7] which are fairly common in overhead athletes such as baseball pitchers, swimmers, gymnasts, racquet sport enthusiasts (eg, tennis players), and rowing/kayak athletes.[8, 9, 10, 11] Trauma may occur because of direct injury to the biceps tendon when the arm is passed into excessive abduction and external rotation. This pattern of shoulder injury can also occur in the left shoulder of right-handed golfers. Many overuse injuries coexist with some degree of bicipital tendinitis and rotator cuff tendinitis.

The athletic shoulder differs qualitatively from the biomechanics of the shoulder in daily life because of the higher energies and repetitive motions that are involved in athletic activities. Sports activities that require repetitive overhead motion with inadequate reparative time may cause the biceps tendon to break down.

See the list below:

• 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.

• 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.

• 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.

• 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]

See the list below:

• 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.

• Flexion of the elbow against resistance aggravates the patient's pain.

• 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.

• 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.

• 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.

• 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.

• Bicipital tendinitis with labral tears or rotator cuff tears may not improve if all the conditions are not treated.

See the list below:

• 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]

• 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.

• 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.

• Labral tears may disrupt the biceps anchor, resulting in dysfunction and causing pain.

• 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]

• 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]

See the list below:

• 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.

See the list below:

• 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.[16, 17] 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.[17] 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.[17] 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.[16] 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.[16]  

  • A review by Carr et al found that MRI can show changes in signal sequence or tears, however, MRI has a low sensitivity and frequently results in missed or misdiagnosed biceps pathology.[18]

  • MRI should be considered after unsuccessful rehabilitation and in cases of suspected rotator cuff injury or labral tear injury.

  • A prospective study by Rol et al analyzed cross-sectional imaging with MRI or CT arthrography data from 25 rotator cuff tear patients and reported that pre-operative imaging is not sufficient to make a diagnosis of long head of biceps tendinopathy.[19]

• Ultrasound and arthrography

  • Some authors have described the use of ultrasound and arthrography to identify tendon lesions.[20, 21]

  • 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.[22]

• Arthroscopy[23, 24]

  • 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.

See the list below:

• 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.[25]

• Judicious use of subacromial and/or glenohumeral joint steroid injections are recommended for persistent cases of bicipital tendinitis.[1, 25] Note: Although injection into the biceps sheath is effective, injection into the tendon itself can result in biceps tendon degeneration and rupture.[26]

• Ultrasonographic-guided percutaneous steroid injections have been described in the literature and may result in better placement with potentially less complications.

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.

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.

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, 27] 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 following[7, 27] :

• 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. Subpectoral biceps tenodesis has proven to be an effective procedure to relieve pain and maintain function.[28]

Consultations

Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.

The goals of pharmacotherapy are to reduce patient morbidity and prevent complications.

Class Summary

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.

Class Summary

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.

Class Summary

Glucocorticoids stimulate synthesis of enzymes that decrease inflammatory responses and suppress the immune system.

Methylprednisolone (Depo-Medrol)

Methylprednisolone is a potent, intermediate-acting glucocorticoid, which has no mineralocorticoid activity. A useful anti-inflammatory and immunosuppressant agent.

Return to activity should not occur until the patient's discomfort and pain is controlled effectively and a monitoring program has been initiated. Some authors recommend waiting 3 weeks after pain has completely resolved before allowing participation in competitive activities.

Individuals who return to a high level of athletic activity too soon may find themselves with symptom flare-ups. Continued straining of an injury that has not healed completely can put the individual at risk for chronic degenerative tissue damage and biceps tendon rupture.

Prevention of bicipital tendinitis is similar to prevention of rotator cuff injuries, including warm-ups before exercise, the use of passive stretching and strengthening exercises, avoidance of painful activities, and the use of proper biomechanics. Increased attention should be made for those athletes at high risk of bicipital tendinitis, such as baseball pitchers. High angular velocity and torques combined with the repetitious nature of pitching results in vulnerability of the shoulder to injury.

Although the prognosis of bicipital tendinitis is dependent upon the degree of injury, most patients do well with treatment (see Treatment: Acute Phase, Recovery Phase, Maintenance Phase, and Surgical Intervention). However, a significant number of patients develop degenerative changes, and spontaneous rupture of the biceps tendon occurs in 10% of patients.

Inform the patient that an increased risk of biceps tendon rupture or chronic inflammatory changes exists if the directed restrictions are not followed.