The characteristic symptom of biceps tendinitis (bicipital tendinitis) is exercise-induced pain in the anterior aspect of the shoulder or elbow joint, which is usually alleviated by rest and analgesia.
Biceps tendon rupture may be caused by trauma or may be the result of the normal aging process.
Rupture of the long head biceps tendon ("Popeye biceps") rarely requires surgical management whereas surgical repair is always needed in a rupture of the distal biceps tendon.
Prevalence
Repetitive strenuous movements predispose the individual to biceps tendinitis.
In athletes, the long head of the biceps is often under a great deal of strain, particularly in sports involving overhead movements, e.g. throwing and swimming.
Smoking increases the risk of biceps tendon rupture 1.
Disorders of the long head of the biceps
Tendinitis
Pain in the anterior aspect of the shoulder is suggestive of tendinitis. Pain may radiate towards the biceps brachii muscle and be aggravated by shoulder movements. Clinical findings include localised pain on palpation in the anterior aspect of the shoulder and pain on movement, particularly during rotational movements.
Provocative tests for the biceps are non-specific, and other shoulder disorders may also elicit a positive test result.
Yergason's test: The patient attempts to supinate the forearm, with the elbow flexed, against resistance applied by the examiner. The test is positive if the patient experiences pain in the anterior aspect of the shoulder.
Speed's test: The examiner applies resistance whilst the patient attempts to flex the upper arm from the horizontal plane with the elbow fully extended, the forearm supinated and the upper arm externally rotated. The patient may experience pain in the anterior aspect of the shoulder. When the test is repeated with the forearm pronated and upper arm internally rotated, no pain will be elicited. The affected tendon becomes symptomatic as strain is applied to the biceps brachii muscle.
An ultrasound examination may reveal effusion and oedema in the tendon sheath 2.
Dislocation
Partial or complete dislocation of the biceps tendon (subluxation or luxation) at the bicipital groove is associated with a traumatic tearing injury of the shoulder.
Pain and tenderness to palpation are similar to that seen in biceps tendinitis. Moreover, the patient may describe a painful snap at the anterior aspect of the shoulder. The examiner may sometimes be able to feel the snap when examining the shoulder. An ultrasound examination will confirm the dislocation of the tendon.
SLAP lesion
A SLAP lesion (superior-labrum-anterior-posterior) affects the attachment site of the long head of the biceps at the top part of the shoulder socket.
A SLAP lesion may result from a sudden, forceful tearing injury, such as using a hand to try to break a fall from a height or falling onto an outstretched hand. Repetitive trauma may also cause a SLAP lesion, for example in the throwing athlete.
The symptoms of a SLAP lesion include nondescript shoulder joint pain associated with overhead use of the arm and a diminished ability to exercise. The patient may also describe a catching sensation in the shoulder.
Rupture
A rupture of the long head biceps tendon is common in elderly men following a sudden exertion that puts strain on the tendon.
The patient usually feels pain in the shoulder on exertion and notices bunching up of the biceps brachii muscle in the affected limb with unusual distal bulging of the muscle (”Popeye biceps”). Bruising may develop in the upper arm. The patient may also recall an audible snap when the tendon ruptures under strain.
Treatment
Tendinitis
The treatment of tendinitis comprises rest, anti-inflammatory drugs, a corticosteroid injection into the painful area and physiotherapy.
Surgical management may be indicated in severe, chronic cases. The procedure employed is usually tenodesis where the tendon is cut off the shoulder socket and reattached to the bicipital groove in the upper part of the humerus.
Dislocation
Symptoms may be alleviated by the following: decreasing the amount of shoulder strain, drug therapy including a cortisone injection and physiotherapy.
Surgery is the only way to treat a symptomatic tendon that has dislocated completely. Any other co-existing injuries, such as a rotator cuff tear, may be repaired during the same surgical procedure.
Rupture
A rupture of the long head biceps tendon does not cause permanent damage, and the lesion does not usually require surgical management. However, the restoration of the normal muscle contour and strength may be hastened with a relatively small surgical procedure.
Injuries of the distal end of the biceps brachii muscle
Tendinitis
The distal biceps tendon inserts on the radius. The tendon may become inflamed in response to repeated strain, particularly when the forearm is subjected to forceful twisting with elbow flexing. In such a case, insertion tendinitis may develop at the tendon attachment site.
The symptoms include nondescript pain in the antecubital fossa and a diminished ability to exercise the limb.
The patient will have localised pain on palpation, around the site of the distal tendon, at the antecubital fossa as well as pain when an attempt is made to supinate the forearm against resistance. The condition is sometimes confused with lateral epicondylitis (tennis elbow), which is a much more commonly encountered problem affecting the same anatomical area.
Rupture
An avulsion of the distal biceps tendon is a problematic but, fortunately, rare injury; it accounts for only 3% of all biceps injuries.
The avulsion is caused by a sudden, violent, straightening force applied to the elbow joint with the forearm in supination. The trauma mechanism may involve, for example, using a hand to try to break a fall from a height or one hand giving way when lifting a heavy object.
Clinical examination will typically reveal an absent distal biceps tendon or the tendon is less prominent to palpation than in the contralateral arm.
There will be proximal retraction of the muscle mass, and the forearm supination strength, with the elbow flexed, will be reduced.
During the acute phase the elbow will be painful with some obvious swelling. After a few days, a haematoma will develop.
An ultrasound examination, and magnetic resonance imaging, may assist diagnosis.
Treatment
The treatment of tendinitis of the distal biceps tendon comprises rest, anti-inflammatory drugs, a corticosteroid injection into the painful area and physiotherapy.
An avulsion of the distal biceps tendon always needs surgical repair 34. The tendon is reattached, using a free tendon graft if necessary. The surgery may be carried out even after a delay of a few years.
References
Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res 2002 Nov;(404):275-83. [PubMed]
Kayser R, Hampf S, Pankow M, Seeber E, Heyde CE. [Validity of ultrasound examinations of disorders of the shoulder joint] Ultraschall Med 2005 Aug;26(4):291-8. [PubMed]
Blackmore SM, Jander RM, Culp RW. Management of distal biceps and triceps ruptures. J Hand Ther 2006 Apr-Jun;19(2):154-68. [PubMed]
Vastamäki M, Vastamäki H. A simple grafting method to repair irreparable distal biceps tendon. Clin Orthop Relat Res 2008 Oct;466(10):2475-81. [PubMed]