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. [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
Arthroscopy may be useful in evaluating chronic shoulder pain. [23, 24] 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. The finding of an inflamed and hyperemic long head of the biceps brachii tendon within the bicipital groove on arthroscopic examination has been described as the “lipstick sign.” [25]
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. [26]
Judicious use of subacromial and/or glenohumeral joint steroid injections are recommended for persistent cases of bicipital tendinitis. [1, 26] Note: Although injection into the biceps sheath is effective, injection into the tendon itself can result in biceps tendon degeneration and rupture. [27]
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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Biceps muscle and tendons.
