Biceps Tendinopathy

Biceps tendinopathy describes a painful inflammation or degeneration of the tendon of the long head of the biceps.  (1,2) The term “tendinopathy” may suggest either an inflammatory or degenerative origin. (3) In the case of a recent acute insult, inflammation (tendinitis) may be a valid explanation.  However, current evidence suggests that many cases of tendinopathy occur without inflammation and are the result of chronic overload, which leads to microscopic tearing, failed healing and subsequent degenerative changes within the tendon.  (3) Injuries that have been present over three months consistently demonstrate fibrosis and degeneration with very little inflammation.  (3)

Biceps Anatomy

The biceps brachii attaches to the shoulder, via two tendons.  The short head connects the medial biceps muscle to the coracoid process of the scapula and is generally not susceptible to tendinopathy.  (5) The more vulnerable long head travels through the intertubercular (bicipital) groove between the greater and lesser tubercles of the humerus, where it is held beneath the transverse humeral ligament.  The tendon then travels obliquely across the humeral head in the “rotator interval” between the supraspinatus (superiorly) and subscapularis (inferiorly), which help to maintain the position of the biceps tendon. (6-8)

The long head of the biceps tendon ultimately inserts intra-articularly on the supraglenoid tubercle of the scapula and the superior glenoid labrum.  (9) Biceps tendinopathy most commonly affects the portion of the tendon proximal to the transverse humeral ligament.  Irritation of the long head of the biceps tendon within the intertubercular groove is termed “primary biceps tendinitis” and is responsible for approximately 5% of all cases of biceps tendinitis.  (1)

The action of the biceps includes forearm supination and elbow flexion.  The short head also assists with shoulder flexion, and the long head plays an important role in shoulder stability by depressing the humeral head (thereby increasing subacromial space) during arm elevation.  (10-12) 

Who is Affected

Biceps tendinopathy is most common in young adults between the ages of 18 and 35. (12)  The condition often results from the repetitive overhead activity, including throwing, swimming, gymnastics, martial arts, racquet sports, and contact sports.  (12-13) 

Subacromial impingement is the most common cause of shoulder complaints and may lead to a plethora of problems, including biceps tendinitis.  (14) In fact, 95% of biceps tendinopathy patients have “shoulder impingement” as their primary diagnosis. (15) Because of common etiologies, biceps tendinopathy rarely occurs in isolation and more than 90% co-exist with other impingement related pathologies of the shoulder, including rotator cuff tendinopathy/tears, labral tears, and shoulder instability. (13,15,16) Compounding the problem, rotator cuff tears may expose the biceps tendon to the coracoacromial arch, making the biceps tendon more vulnerable to impingement.  (16)

Bio Mechanical Risk Factors

Additional biomechanical risk factors for the development of biceps tendinopathy include repetitive shoulder or elbow flexion, repetitive overhead activity, improper lifting technique, shoulder girdle muscle imbalances, poor posture, inflexibility, scapulothoracic or glenohumeral instability, repetitive eccentric overload, trauma, and osseous anatomical abnormalities that narrow the bicipital groove, including fracture, osteoarthritis, and congenital variations.  (17) 

Patients with bicipital tendinopathy often complain of a deep throbbing ache over the anterior shoulder or bicipital groove.  (4,18) The pain may refer to the deltoid insertion and less frequently toward the elbow or hand in a radial distribution.  (4,18) Symptoms are often provoked by repetitive overhead activity and movements that require forearm supination, shoulder flexion, or elbow flexion.  (18,19) Symptoms increase when initiating activity.  (18) Nocturnal symptoms are common, particularly when sleeping on the affected shoulder.  (18,19) Patients often report mild relief from palliative measures, including heat, ice, stretching, and massage.  (18) Symptoms may be documented and monitored by use of the disabilities of the arm, shoulder, and hand (DASH) and quick DASH.

Tendon Rupture

Clinicians should be wary of biceps tendon rupture, as this is one of the most common musculotendinous tears.  (19)  Tendon rupture is suggested by a history of a painful audible pop, followed by relief. Risk factors associated with the biceps tendon rupture include chronic tendinopathy, concurrent rotator cuff tear, contralateral biceps tendon rupture, age over 40, poor conditioning, and the presence of rheumatologic disease.  (19) 

Clinical evaluation of biceps tendinopathy will often demonstrate limited range of motion.  Active or resisted movements may provoke pain with forearm supination, elbow flexion, and shoulder flexion. Popping, catching, or locking movements during active range of motion testing may suggest a labral injury.  (20)  Palpation should elicit the most characteristic finding of tenderness in the rotator interval and bicipital groove.  (1,21,22) Ecchymosis & swelling with a visible bulge (Popeye deformity) where the muscle has retracted toward the elbow indicate tendon rupture.  (19,58)

Tests

Orthopedic assessments for bicipital tendinitis include Yergason’s, Speed’s, Bear Hug, Belly Press, and Upper Cut tests.  (20,23-28) The most sensitive tests are the Bear Hug (0.79) and Upper Cut (0.73), and the most specific are Belly Press (0.85) and Speed’s test (0.81). Upper Cut is considered the most accurate of all tests. (23) The Upper Cut Test is performed as the clinician applies resistance while the patient attempts to “quickly make an uppercut motion from the waist toward chin level.” Pain or popping suggests biceps tendon involvement.

Speed’s test is performed as the patient tries to flex his/her straightened arm against resistance, first with the hand in supination, then comparing symptoms when the test is performed in pronation. Neer and Hawkin’s test may also help identify biceps tendon pathology, although these tests will also provoke impingement-type symptoms, making differentiation more challenging.  (20,29,30) When necessary, differentiation of biceps and rotator cuff tendinopathy may be confirmed by injection of a local anesthetic into the subacromial space.  (31)

The Lippman test is used to help identify “primary biceps tendinitis” within the bicipital groove.  The test is performed on a seated patient with his/her arm at the patient’s side, elbow flexed to 90 degrees, forearm pointing forward. The clinician moves the patient’s forearm through internal and external rotation while palpating the biceps tendon in the bicipital groove.  Pain suggests biceps tendon involvement while displacement suggests the possibility of recurrent biceps tendon subluxation and/or instability.  Rupture of the transverse humeral ligament is a possibility.

Scapular Dysfunction

The theory of “regional interdependence” states that musculoskeletal problems may be directly impacted by dysfunction in other sites along the biomechanical chain.  (32)  Clinicians should carefully assess for dysfunction in the cervical and thoracic spine and identify biomechanical faults, including scapular dyskinesis and upper crossed syndrome.  (33,34) Scapular dysfunction may be assessed by observing for scapular winging and the presence of altered scapulohumeral rhythm.  (35) Clinicians should consider posterior capsule tightness, particularly in throwing athletes, by assessing for deficits in passive internal rotation with the arm abducted to 90 degrees and also with the hand behind the back.  (36)

Radiology

Plain film imaging is of little value for the assessment of the biceps tendon but may identify osseous sources of impingement or other bony pathology.  When indicated, standard views should include: AP (performed with shoulder Internal Rotation), Grashey, also known as Neer AP or True AP (performed with shoulder External Rotation), Lateral axillary, and Arch or Rockwood views to provide some assessment of available subacromial space. (76) “Fisk views” help assess the size of the bicipital groove.  (37)  Bicipital tendon calcifications are sometimes evident on plain films.  (37) Ultrasound is a useful imaging technique for the biceps tendon. (39-45) MRI may help identify ruptures of the long head of the biceps tendon or concurrent pathology, including rotator cuff lesions and labral tears.  (46,47) Overall, the evidence suggests that ultrasound and MRI are similar for assessing patients with suspected biceps abnormalities. (74-76)

Due to similar mechanisms of injury and indistinguishably blended anatomy, lesions of the bicep tendon are difficult to differentiate from rotator cuff pathology or labral tears.  (48) Biceps tendinopathy often co-exists with these and other pathologies of the shoulder.  (15,19,48)           

Diagnostic Considerations

Additional differential diagnostic considerations for biceps tendinopathy include adhesive capsulitis, biceps tendon rupture, cervical radiculopathy, brachial neuritis, AC joint pathology, glenohumeral arthritis or instability, osteonecrosis of the humeral head, subacromial impingement syndrome, fracture, neoplasm, and rheumatologic disease. 

Conservative care is the most appropriate management for the majority of biceps tendinopathy patients.  (49) Traditional measures include rest, ice, activity modification, and functional re-training.  (21,50) The first phase of treatment is directed at pain relief and restoration of normal motion.  (51,52) Patients should limit activities that require repetitive overhead activity, elbow flexion, or forearm supination.  Patients should specifically avoid military presses, upright rows, and wide-grip bench presses.  (52) Therapeutic modalities, including ice, heat, ultrasound, microcurrent, or e-stim may be appropriate to control symptoms as needed.  (52)

Rehabilitation

The goal of rehab should be to establish a full, balanced, pain-free range of motion.  (53) Soft tissue techniques may include transverse friction massage or IASTM over the biceps tendon.  Myofascial release and stretching exercises may be appropriate for the biceps, cervical spine, shoulder, and periscapular musculature. Mobility exercises may include pendulum circumduction, wall walking, cane/wand stretching in flexion and abduction, cross body and sleeper stretches. The first phase of treatment should include early scapular stabilization exercises, via activation of the lower trapezius and serratus anterior.  Examples of these exercises include YTWL and scapular protraction.

As patients recover, strengthening may progress from isometric to concentric, then eccentric, and, finally, sports specific rehab.  (51) Early strengthening exercises may include resisted internal and external rotation, low rows, and concentric biceps strengthening.  Eccentric loading for the management of tendinopathies is a proven beneficial strategy and may be implemented as the patient recovers.  (51,54,71,72) Advanced strengthening exercises may include a bear hug, reverse fly, and resisted internal/external rotation at 90 degrees of abduction.  (52) A functional study of biceps activation by Borms provides a detailed continuum of advanced progressive biceps loading exercises. (73)

Address Bio Mechanical Deficits

Clinicians must address associated biomechanical deficits, including spinal intersegmental joint dysfunction, scapular dyskinesis, and upper crossed syndrome. Limited cervicothoracic mobility, including a forward flexed posture, limits normal scapulohumeral rhythm and predisposes the shoulder to impingement-related disorders.  There is evidence to suggest that cervicothoracic and thoracic spine manipulation is appropriate for patients with shoulder pain.  (33,55-57) Spinal manipulation may help decrease shoulder pain while improving mobility and function.  (33,55)

Conclusion

Medical management of biceps tendinopathy may include NSAIDs.  (66) Ultrasound-guided, local anesthetic injection into the biceps tendon sheath may provide palliative relief for patients with primary biceps tendinitis, although injections directly into the tendon may increase the risk of rupture. (59-63) Ultrasound guidance may produce up to a five-fold increase in analgesia.  (64,65)

Surgery is generally not considered for biceps tendinopathy unless prolonged (greater than three months) conservative measures have failed.  (66) Even in cases of tendon rupture, the value of surgery is questionable.  Patients with a complete rupture of the long head of the biceps tendon demonstrate 11-16% diminished strength in elbow flexion, forearm supination, and shoulder abduction.  (67)  Strength losses post-surgical repair range from 7-20%.  (67)  Surgical repair (tenodesis) is usually reserved for younger individuals (under 60 years of age), athletes, and manual workers.  (67-70) Recalcitrant cases may require tenotomy (tendon stump removal) or correction of anatomical origins of chronic impingement.  (Type III acromion, spurring, etc.)  (67,68)  

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