ICD-10-CM Codes

Key Concepts

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  Biceps anatomy

  
  
  
  
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    The biceps brachii is composed of two muscles. The long head of the biceps tendon (LHBT) originates on the supraglenoid tubercle and attaches to the superior labrum.

  
  

Proximal Biceps Injury

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  Injury is common in overhead athletes.

  
  
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  Bicipital tendinitis

  
  
  
  
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    An overuse syndrome caused by repetitive overload of the biceps tendon from elbow flexion and supination; often occurs with impingement syndrome.

  
  
  
  
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  Rupture

  
  
  
  
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    Ninety-six percent of biceps ruptures involve the proximal LHBT, 3% the distal head, and 1% the short head.

    
    
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    Most common in older individuals (ages 40 to 60 years), affecting more men than women.

    
    
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    Biceps tendinitis may predispose to rupture.

    
    
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    Most ruptures result in a characteristic “Popeye” muscle appearance.

  
  
  
  
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  Biceps tendon subluxation/dislocation across the bicipital groove can be caused by a tear in the subscapularis tendon

History

Patients will often complain of anterior shoulder pain that increases with overhead activities, elbow flexion, and/or supination. Later in the course of the disease, pain may be more notable at night or while resting. Pain often radiates distally and can be compounded by concomitant impingement syndrome or rotator cuff tendinitis. In the setting of proximal biceps tendon rupture, most patients recall a single acute injury with an audible “pop” noted by the patient.

Physical Examination

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  Inspection: Evaluate for “Popeye” appearance of biceps muscle caused by retraction of the LHBT distally ( Fig. 31.1 ). Ecchymosis may be noted if injury is relatively acute.

  
  

  
  

  
  

  

  
  

  
  

  “Popeye” muscle seen in proximal biceps tendon rupture.

  
  

  (From Johnson DL, Mairs SD, eds. Clinical Sports Medicine. St. Louis: Mosby; 2006:237.)

  
  
  
  
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  Palpation: Bony palpation of the sternoclavicular joint, intrinsic shoulder bones, and cervical spine is recommended. Soft-tissue palpation should include palpation of the long and short heads of the biceps muscle, the rotator cuff muscles, and the anterior and posterior capsules.

  
  
  
  
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    With bicipital tendinitis, point tenderness with palpation of long head tendon at the bicipital groove is common. Point tenderness should move in conjunction with the bicipital groove as the examiner rotates the affected arm. Comparing the contralateral shoulder is helpful.

  
  
  
  
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  Range of motion: Both passive and active range of motion of the shoulder and elbow should be evaluated. In the acute setting, motion may be limited secondary to pain.

  
  
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  Neurovascular examination: Sensation and distal pulses of the upper extremity should be evaluated.

Special Tests

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  Speed test: With the affected shoulder in 90 degrees of forward flexion, the forearm is extended and supinated. The examiner then applies a downward pressure on the palm. A positive test is pain over the bicipital groove (sensitivity [Sn] 54%, specificity [Sp] 81%).

  
  
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  Yergason test: The elbow is flexed at 90 degrees with the forearm in pronation with active resistance against supination. A positive test is pain over the bicipital groove or subluxation of the LHBT at the bicipital groove (Sn 41%, Sp 79%).

  
  
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  Ludington test: Patient places both hands behind head with interlocking fingers, flexing biceps muscles. A positive test is pain at the bicipital groove or a notable subluxing tendon. This may elicit the “Popeye” sign (see Fig. 31.1 ).

  
  
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  Upper cut: Shoulder in neutral position with forearm at 90 degrees and supinated. The patient creates an upper-cut motion while the examiner resists while allowing for movement. A positive test is pain or popping over the anterior shoulder during the resisted movement (Sn 73%, Sp 78%). One study found that combining the uppercut test with tenderness at the bicipital groove demonstrated the most value to diagnostic accuracy.

  
  
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  Consider testing for concomitant rotator cuff tears and labral tears.