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Basics ⬇

Author(s): Daniel C.Herman, MD, PhD, FAAPMR, FACSM, CAQSM and Giorgio A.Negron, MD

Description

  • Overuse injury of the long head of the biceps muscle
  • Initially begins as inflammation in the tendon sheath known as tenosynovitis and then progresses to tendon degeneration and disordered arrangement of collagen fibers, otherwise known as tendinosis or biceps tendinopathy
  • Primary biceps tendinitis (inflammation of the tendon) is estimated to represent only 5% of cases (1).

Epidemiology

80% of bicep tendinopathy cases are seen in males with peak incidence in the 5th and 6th decade of life (2).

Etiology and Pathophysiology

  • Anatomy:
    • The long head of the biceps muscle arises from the superior glenoid labrum and the supraglenoid tubercle of the scapula.
    • It is an intra-articular but extrasynovial structure.
    • Primary blood supply proximally is the anterior humeral circumflex artery.
  • Biomechanics:
    • Primary function of the biceps at the elbow is a flexor and supinator.
    • In the shoulder, the biceps tendon may act as a humeral head depressor and a secondary stabilizer of the glenohumeral joint.
    • During throwing, it assists in deceleration of the humerus.

Risk-Factors

Repetitive use of upper extremities (especially overhead), such as throwing/hitting, swimming, racquet sports, and gymnastics

Commonly Associated Conditions

  • Rotator cuff pathology (tendinopathy, impingement, tears)
  • Glenoid labral tears (superior labrum anterior and posterior [SLAP] lesions)
  • Subluxation/dislocation of the long head of the biceps
  • Biceps tendon rupture

Diagnosis ⬆ ⬇

History

  • Anterior shoulder pain localized over the bicipital groove, which may radiate distally toward the biceps
  • Pain is aggravated by overhead activities or lifting objects.

Physical Exam

  • Point tenderness over the bicipital groove with the arm in 10 degrees internal rotation (sensitivity: 54%; specificity: 72%) (3)
  • An audible or palpable snap during arc of motion while throwing may indicate instability or subluxation of the biceps tendon.
  • A large mass (“Popeye deformity”) in the upper arm, ecchymosis, and swelling following a painful audible pop with quick resolution of pain could indicate biceps tendon rupture.
  • Any positive testing for biceps tendon pathology may also signify a glenoid labral tear (SLAP lesion).
  • Special tests:
    • Uppercut test: With the patient’s shoulder in neutral position and forearm supinated, elbow is flexed 90 degrees with hand in a fist. Patient then rapidly brings fist toward chin against resistance. Pain in the shoulder is considered a positive test (sensitivity: 73%; specificity: 78%) (3).
    • Speed test: With the patient’s shoulder elevated to 90 degrees of forward flexion, elbow extended and forearm supinated, the patient flexes the shoulder against resistance. Pain in or about the bicipital groove is considered a positive test (sensitivity: 54%; specificity: 81%) (3).
    • Yergason test: With the patient’s elbow flexed to 90 degrees, the patient supinates against resistance. Pain over the biceps tendon in the bicipital groove is considered a positive test (sensitivity: 41%; specificity: 79%) (3).
    • Performing the uppercut test and biceps groove tenderness together has the highest sensitivity and specificity to clinically diagnose long head biceps pathology (3)[A].

Differential Diagnosis

  • Rotator cuff tendinopathy
  • Impingement syndrome
  • Glenoid labral tears
  • Biceps tendon subluxation/dislocation
  • Subacromial bursitis
  • Acromioclavicular joint separation or arthritis
  • Pectoralis minor strain
  • Glenohumeral joint arthritis
  • Thoracic outlet syndrome
  • Cervical disk disease
  • Brachial plexus injuries
  • Rheumatoid arthritis
  • Pancoast tumor

Diagnostic Tests & Interpretation

  • Plain-film radiographs are not helpful in the diagnosis of biceps tendon pathology. Magnetic resonance imaging (MRI) may show increased signal on T2-weighted images in the area of the biceps tendon and is beneficial for detecting complete tears (sensitivity: ~60%; specificity: ~100%) (4)[B]. Also useful in detecting pathology of the superior labrum and rotator cuff. Magnetic resonance (MR) arthrography may be superior to conventional MRI in diagnosing biceps tendon lesions and SLAP lesions but is invasive (sensitivity: ~90%; specificity: ~50%) (1,4)[B].
  • Dynamic musculoskeletal ultrasound (US) is becoming more popular in diagnosing biceps tendon rupture, subluxation, and dislocation (sensitivity: 49%; specificity: 97%) (1). It is not reliable in evaluating intra-articular tears or the glenoid labrum. US is very operator- and facility-dependent. Advantages include low cost and lack of radiation exposure.

Treatment ⬆ ⬇

Acute treatment:

  • Rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or acetaminophen
  • Rest should not include prolonged immobilization because this may lead to adhesive capsulitis (frozen shoulder).
  • Gentle stretching and range of motion (ROM) exercises should be initiated early once symptoms begin to improve.
  • Consider physical therapy for persistent symptoms.
  • Surgery is reserved for refractory cases.

Additional Therapies

  • Physical therapy:
    • Gentle ROM exercises are begun first.
    • Scapulothoracic stabilization exercises
    • Rotator cuff strengthening
    • Biceps strengthening
  • Include:
    • US: uses sound waves to heat up the affected tissues
    • Phonophoresis: uses US waves to drive topical corticosteroid medication into the affected tissue
    • Iontophoresis: uses electric current to drive a corticosteroid into the affected tissue (5)[C]

Surgery/Other Procedures

  • Injections:
    • Corticosteroid injection into the biceps tendon sheath may be considered providing short-term pain control up to 6 wk, but controversy exists regarding the accuracy of such injections (5):
      • US may increase the accuracy and analgesic effect (1).
    • Injection into the tendon itself has been associated with tendon rupture and should be avoided.
  • Surgical options may be considered for patients who fail conservative treatment after 3 mo or have refractory pain (1):
    • Tenotomy: surgical release of the long head of the biceps tendon at or near its superior glenoid labral origin:
      • Recommended in older patients with low activity requirements
      • Disadvantage includes a cosmetic “Popeye deformity” and possible loss of some strength with supination.
      • Minimal rehabilitation is required.
    • Tenodesis: fixation of the long head of the biceps tendon in the bicipital groove:
      • Minimal loss of function compared with tenotomy
      • No cosmetic defect
      • Recommended in younger, more active individuals
      • Disadvantages include a more complex operation, a period of immobilization, and longer postoperative rehabilitation.
  • Proximal rupture of the long head of the biceps typically relieves symptoms of pain without significant loss of function. Surgery may be considered if there is significant loss of strength or function.

Additional Reading ⬆ ⬇

  • Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007;89(8):1001–1009.
  • Friedman DJ, Dunn JC, Higgins LD, et al. Proximal biceps tendon: injuries and management. Sports Med Arthrosc Rev. 2008;16(3):162–169.
  • 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. 2009;43(8):603–607.
  • Patton WC, McCluskey GM III. Biceps tendinitis and subluxation. Clin Sports Med. 2001;20(3):505–529.

References ⬆ ⬇

  1. Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 2009;80(5):470–476.
  2. Donaldson O, Vannet N, Gosens T, et al. Tendinopathies around the elbow part 2: medial elbow, distal biceps and triceps tendinopathies. Shoulder Elbow. 2014;6(1):47–56.
  3. Rosas S, Krill MK, Amoo-Achampong K, et al. A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps. J Shoulder Elbow Surg. 2017;26(8):1484–1492.
  4. Dubrow SA, Streit JJ, Shishani Y, et al. Diagnostic accuracy in detecting tears in the proximal biceps tendon using standard nonenhancing shoulder MRI. Open Access J Sports Med. 2014;5:81–87.
  5. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008;466(7):1539–1554.

Clinical Pearls ⬆

  • Primary biceps tendinitis is very rare and thought to be ~5% of cases.
  • Performing the uppercut test and biceps groove tenderness together has the highest sensitivity and specificity to clinically diagnose long head biceps pathology.
  • Imaging should be considered with shoulder radiography to rule out primary causes of impingement followed by advanced imaging with either US and/or MRI.
  • Nonsurgical measures include rest, NSAIDs, acetaminophen, and physical therapy. Corticosteroid injection in bicipital tendon sheath may provide short-term alleviation of pain.