Biceps Tendinopathy

Abstract

Biceps tendon injuries are typically overuse injuries that impact shoulder function. Symptoms involve complaints of anterior shoulder pain that are worse with activities involving elbow flexion and overhead movement. Work-up should include ultrasound or magnetic resonance imaging of the region to assess for tendonosis. Fortunately, treatment modalities including activity modification, medication, physical therapy, and injections assist in managing the pain and facilitating recovery.

Keywords

Biceps, Shoulder, Tendinitis, Tendinosis, Tendonitis, Tendonopathy

Synonyms
Biceps tendinosis Bicipital tendinitis Bicipital tenosynovitis
ICD-10 Codes
M75.20	Bicipital tenosynovitis, unspecified shoulder
M75.21	Bicipital tenosynovitis of right shoulder
M75.22	Bicipital tenosynovitis of left shoulder
M75.30	Calcifying tendinitis of shoulder, unspecified
M75.31	Calcifying tendinitis of right shoulder
M75.32	Calcifying tendinitis of left shoulder

Definition

First documented in 1932, the term biceps tendinitis was used to describe inflammation, pain, or tenderness in the region of the long head biceps tendon. More recently, tendinitis has been replaced by the term tendinopathy to reflect the more typical nature of injury secondary to degeneration of the tendon (-osis) versus inflammation of the tendon sheath (-itis). Both represent overuse injuries of the biceps tendon, which helps prevent superior translation of the humeral head during shoulder abduction and is intimately associated with the labrum. The biceps tendon works in concert with the rest of the shoulder muscles to maintain dynamic shoulder stability and function.

Primary biceps tendinitis describes isolated inflammation of the long head tendon as it runs in the intertubercular groove, which typically occurs in the younger athletic population. The precipitating factors in primary biceps tendinitis are multifactorial, including repetitive overuse and overhead activities, secondary impingement due to scapular dyskinesis, unilateral instability, and multidirectional shoulder instability. A flat medial wall or shallow bicipital groove can predispose to subluxation of the long head tendon, increasing risk for inflammation. On the other hand, biceps tendinosis is typically seen in the older population (i.e., athletes >35 years or non-athletes >65 years) and is more common than primary biceps tendinitis. In fact, histopathologic studies reveal a paucity of inflammatory findings in the majority of biceps tendons that are the source of anterior shoulder pain. Rather, chronic degenerative changes are most prominent, similar to other tendinopathies of the body. Studies have found that up to 95% of patients with biceps tendinosis have associated rotator cuff disease.

Symptoms

Biceps tendinopathy usually presents with complaints of anterior shoulder pain that is worse with activities involving elbow flexion. Pain usually localizes to the bicipital groove with occasional radiation to the arm or deltoid region. Often, pain will also occur with prolonged rest and immobility, particularly at night. The throwing athlete often describes pain during the follow-through of a throwing motion and may feel a “snap” if the tendon subluxes in the groove. Attention should be given to onset, duration, and character of the pain. Some individuals present with only complaints of fatigue with shoulder movement. A history of prior trauma, athletic and occupational endeavors, and systemic diseases should be considered in evaluating the shoulder. Patients with accompanying impingement syndrome often complain of a “pinching” sensation with overhead activities and a “toothache” sensation in the lateral proximal arm. Biceps tendinopathy pain can be difficult to differentiate from impingement or rotator cuff syndrome, and these entities commonly coexist.

Physical Examination

The physical examination begins with careful inspection of the shoulder and neck region. Attention is given to prior scars, structural deformities, posture, and muscle bulk. Determination of the exact location of pain can be helpful for diagnosis. Biceps tendinopathy commonly presents with palpable tenderness over the bicipital groove ( Fig. 12.1 ). Side-to-side comparisons should be made because the tendon is typically slightly tender to direct palpation. Tenderness over the lateral aspect of the shoulder suggests bursitis, rotator cuff tendinopathy, or strain of the deltoid muscle. Caution should be used, as the accuracy for palpating the biceps tendon was 5.3% in residents and fellows. Range of motion limitation is not seen in isolated biceps tendinopathy, but is often seen in concomitant degenerative joint disease, impingement syndrome, rotator cuff tendinopathy, or adhesive capsulitis. A neurologic examination should be normal, including sensation and deep tendon reflexes. On occasion, strength is limited by pain or disuse. Assessment of the kinetic chain, including scapular stability and spine stabilization, is important.

Special tests of the shoulder should be performed routinely. The Speed and Yergason tests ( Figs. 12.2 and 12.3 ) are often used to help evaluate for biceps tendinopathy. Unfortunately, a recent meta-analysis suggests that these tests are not sensitive (Speed = 50% to 63%, Yergason = 14% to 32%) or specific (Speed = 60% to 85%, Yergason = 70% to 89%) for diagnosing biceps tendinopathy. Impingement tests and supraspinatus tests will help assess for any concurrent rotator cuff tendinopathy. Other maneuvers to assess for instability (anterior apprehension, anterior-posterior load and shift), labral disease (O’Brien test; see Chapter 15 ) and acromioclavicular joint arthritis (Scarf or Cross Arm Adduction test; see Chapter 10 ) should be performed.