Bicipital tendonitis [also called biceps tendinitis or tendionpathy], or, is an inflammatory process of the long head of the biceps tendon.
Bicipital tendinitis can occur due to impingement or rotator cuff injuries, tears of glenoid labrum, and other intra-articular pathologies.
Pathophysiology of Bicipital Tendonitis
Biceps has its origins from two heads. The long head biceps originates from the upper edge of the glenoid labrum and supraglenoid tubercle lies in the bicipital groove of the humerus between the greater and lesser tuberosities before meeting the shart head which originates from coracoid process.
Long head and short head which merge to form biceps brachii muscle, a supinator, and flexor of the forearm and inserts on radial tuberosity in the elbow.
The long head of the biceps tendon helps to stabilize the humeral head, especially during abduction and external rotation.
Bicipital tendonitis frequently occurs from overuse and is common in common baseball pitchers, swimmers, gymnasts, racquet sports enthusiasts, and rowing athletes. Direct trauma to biceps tendon especially in the position of excessive abduction and external rotation may also be the cause.
Degenerative changes in rotator cuff disease may affect the biceps tendon as well.
External rotation of the humerus at or above the horizontal level compresses biceps tendon and rotator cuff to the anterior acromion and repeated episodes may lead to degenerative changes. Hyperlaxity may result in excessive motion of the humeral head and thus injury.
Apart from this, tears of the labrum may disrupt biceps anchor, causing dysfunction and pain. The transverse humeral ligament disruption of the ligament can lead to subluxation of the biceps tendon. Any space occupying lesion like osteochondroma in the bicipital can displace the tendon and cause tendonitis.
Presentation of Bicipital Tendonitis
Anterior shoulder pain, which is exacerbated by movement, lifting or elevated pushing or pulling is the main complaint. Occasionally, shoulder instability and subluxation can be associated with biceps degeneration as the long head of biceps also acts as shoulder stabilizer.
Local tenderness is usually present over the bicipital groove [ About 3 inches below the anterior acromion]. Flexion of the elbow against resistance worsens the pain.
Pain with resisted supination of the wrist with the elbow flexed at 90° and the arm adducted against the body [to cause external rotation at the shoulder at the same time] is also present [Yergason test]
Another test for bicipital tendinopathy where the pain is produced on downward resistance with the patient’s shoulder in slight flexion and elbow in full extension and forearm supinated. [Speed Test]
Yergason and Speed test are demonstrated below.
Shoulder range of motion is usually normal and stable. If not, rotator cuff and glenoid labrum abnormalities should be ruled out. A complete evaluation includes a complete neurovascular assessment.
Rupture of biceps tendon may also be a presentation of biceps tendonitis in some cases. It is usually reported as a sudden and painful popping sensation which may be preceded by a history of shoulder pain. The pain quickly resolves after a painful snap occurs.
The rupture causes the muscle belly to retract [Popeye deformity]
Lab Studies
Laboratory tests are usually not required.
Imaging
Radiographs are generally not helpful or necessary in cases of isolated bicipital tendinitis. Calcifications may be observed with special views like the bicipital groove view.
Radiographic help to rule shoulder pathology like neoplasm and subacromial spurring which may the cause of pain.
Magnetic resonance imaging is not routinely required. It may be done in after unsuccessful treatment or in suspected rotator cuff injury or labral tear injury.
Treatment of Bicipital Tendonitis
In the acute phase, rest should be provided to the affected limb. Over the shoulder, movements should be restricted.
Ice should be applied to the affected area for the first 48 hours. Nonsteroidal anti-inflammatory drugs are recommended for about 4 weeks.
Local injection of an anesthetic and steroid in the bicipital groove can be given. The injection can be repeated after a month if the relief is lacking. Overhead activities should be restricted for 30 days after the injection.
There is an increased risk of biceps tendon rupture from repetitive injections.
Following the acute phase, physical therapy and rehabilitation are started to improve strength and flexibility.
The maintenance phase concentrates on the patient developing increased strength and endurance on the affected side with continued isotonic and isokinetic stretching. Limited participation in sports activities is allowed.
Usually, the patient does not require surgical intervention which should be considered only after a 6-month trial of conservative care has failed. Arthroscopic decompression and acromioplasty is the usual procedure.
Tenodesis is a procedure which moves the attachment of the biceps tendon origin from its original place to a position on the arm so that the tendon is out of the way of the shoulder joint. It is recommended if there is tear or atrophy involving > 25% biceps tendon thickness, severe subluxation of the tendon from the bicipital groove, loss of groove anatomy or there is a failure of surgical decompression.
Biceps tendon rupture older than 6 weeks is not repaired
Prognosis
Most patients do well with the treatment. Degenerative changes, however, can develop in a number of patients develop degenerative changes. About 10% will have spontaneous rupture of the biceps.
Use of warm-up exercises, stretching and strengthening exercises and the use of proper techniques can prevent bicipital tendonitis.
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