AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Biceps tendinopathy describes pain and tenderness in the region of the biceps tendon. The biceps musculotendinous junction is particularly susceptible to overuse injuries, especially in individuals performing repetitive lifting activities. This condition is often diagnosed incorrectly and confused with rotator cuff tendinopathy. Biceps tendinopathy is rarely seen in isolation. It coexists with other pathologies of the shoulder, including rotator cuff tendinopathy and tears, shoulder instability, and imbalances of the dynamic stabilizers. Of patients with biceps tendinopathy, 95% have "impingement syndrome" as their primary diagnosis (Curtis, 1993).

Pathophysiology

Historically, all disorders of the biceps tendon have been termed biceps tendinitis. Recent evidence suggests that degenerative changes in the tendon occur without inflammation. In acute cases, an inflammatory pathology may still be a valid explanation of biceps tendon pain.

Tendinitis describes inflammation of the tendon and the paratendon. This is usually caused by chronic overload, leading to microscopic tears in the tendon, which triggers an inflammatory response. Peritendinitis is the inflammation of the paratendon or tendon sheath. This usually occurs as a result of a direct injury or irritation in which the tendon rubs over a bony prominence; this is referred to as a tenosynovitis. Tendinosis is a histological definition describing degenerative changes in the tendon (Puddu, 1976).

Macroscopic evaluation of a degenerative tendon reveals disorganized tissue that is soft and yellow or brown (mucoid degeneration) (Rees, 2006). The microscopic appearance reveals degenerative changes to collagen with fibrosis (Rees, 2006). Inflammatory mediators are not usually present in tendinosis. The term tendinopathy refers to the clinical presentation of a symptomatic tendon. The underlying pathology, degenerative or inflammatory, is not considered in this definition.

Three etiologies of tendinopathy have been described. The mechanical theory of tendinopathy states that repetitive loading of the tendon results in microscopic degeneration. Fibroplasia occurs within the tendon, resulting in scar tissue. The vascular theory states that tendon degeneration occurs as a result of focal areas of vascular compromise. A newer theory is based on neural modulation. This theory focuses on the assumption of neurally mediated mast cell degranulation and release of substance P. More studies are needed to more clearly understand the relationship between the peripheral nervous system and tendinopathies (Rees, 2006).

The anatomy of the biceps brachii muscle is important in understanding biceps tendinopathy. The biceps brachii has 2 heads. The short head arises from the tip of the coracoid process of the scapula. The long head arises from the supraglenoid tubercle of the scapula and the superior labrum runs through the intertubercular groove between the greater and lesser tubercles of the humerus. Proximally, the long head of the biceps acts as a shoulder stabilizer through depression of the humeral head (Kumar, 1989). The 2 heads join together in the distal arm to form one strong tendon, which inserts on the radial tuberosity on the upper end of the radius. Distally, the tendon gives off the bicipital aponeurosis (an expansion that blends with the flexor forearm muscles, extending to the ulna). The biceps brachii is innervated by the musculocutaneous nerve (C5, C6).

The actions of the biceps brachii muscle is flexion of the elbow, supination of the forearm, humeral head depression, and shoulder flexion (short head primarily).

Frequency

United States

Biceps tendinopathy is a common condition, but the exact frequency is unknown.

CLINICAL

Section 3 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

Diagnosis is primarily clinical. Patient history suggests the diagnosis.

• Pain is reported in the region of the anterior shoulder located over the bicipital groove, occasionally radiating down to the elbow.
• The pain is aggravated by activities that require shoulder flexion, forearm supination, and/or elbow flexion.
• Pain is usually exacerbated by initiating activity.
• Some describe fatigue with shoulder movements.
• The symptoms are alleviated by rest, ice, massage, stretching, and, sometimes, heat.
• Night pain is not uncommon.

Physical

• Inspection - Muscle bulk of the shoulder girdle, anatomical abnormalities, posture
• Palpation - For tenderness over the biceps tendon in the bicipital groove; compare side to side (because often tender in asymptomatic patients)
• Range of motion (ROM) - Passive and active of the shoulder in forward flexion, extension, abduction, adduction, internal and external rotation
• Neurological testing - Muscle strength, sensation, and deep tendon reflexes; strength testing possibly limited by pain
• Special biceps tests
• • The Speed test 1: With the forearm in the supinated position and the elbow fully extended, the patient attempts to flex the arm (forward flexion at the shoulder) against the resistance provided by the examiner. Tenderness in the bicipital groove is considered a positive test result and is indicative of bicipital tendinitis.
  • The Speed test 2: This test is a variation on the Speed test 1. Test 2 may be performed by having the patient forward flex the arm to 90° while the examiner tries to move the patient's arm into extension against resistance provided by the patient. A positive test result is indicated by discomfort or pain in the bicipital groove.
  • The Yergason test: The patient's elbow is flexed to 90° and is stabilized against the thoracic cage with the forearm pronated, and the examiner resists supination while the patient also laterally rotates the arm against resistance. The test is considered positive if the patient experiences discomfort or pain in the bicipital groove or if the tendon pops out of the groove.
  • The Gilchrist test: The patient lifts a 5-pound weight overhead with an externally rotated arm and slowly lowers it to the lateral horizontal position. Discomfort or pain in the bicipital groove is considered a positive test result.
  • The Lippman test: With the patient's arm flexed to 90°, the examiner palpates the biceps tendon 3 inches (7.6 cm) below the glenohumeral joint and moves the biceps tendon from side to side. Pain and a palpable displacement of the tendon from its groove indicate tenosynovitis with instability of the biceps tendon.
• Other tests - For associated rotator cuff, labral, and acromioclavicular joint pathology
• • Impingement tests include the Hawkins-Kennedy test and the Neer test.
  • Acromioclavicular joint tests include the cross-body adduction test.
  • Labral tests include the O'Brien test, the anterior slide test, and the Clunk test.

Causes

• Poor lifting techniques
• Chronic repetitive upper extremity activities (shoulder/elbow flexion)
• Impingement syndrome
• Rotator cuff pathology
• Biceps subluxation
• Shoulder girdle muscle imbalances
• Poor posture
• Overload (usually eccentrically)
• Lack of flexibility/capsular tightness
• Direct trauma
• Multidirectional shoulder instability
• Calcifications of the tendon
• Osteoarthritis and spurring
• Anatomical abnormalities (eg, variations of the bicipital groove, fractures, first rib subluxations)

DIFFERENTIALS

Section 4 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Acromioclavicular injury
Cervical radiculopathy
Labral tear
Musculocutaneous neuropathy
Shoulder instability
Suprascapular neuropathy
Referral from visceral organs

WORKUP

Section 5 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• No laboratory studies are necessary.

Imaging Studies

• Plain radiography may show calcifications in the biceps tendon or associated degenerative findings of the glenohumeral or acromioclavicular joint. Fisk views help evaluate the size of the biceps groove. Short, narrow margins of the groove may predispose to biceps tendon subluxations (Fisk, 1965).
• Ultrasonography can be used to assess the dynamic function of the biceps tendon. It is also useful for diagnosing biceps ruptures or instability.
• MRI is performed to rule out shoulder pathology (eg, rotator cuff tear, labral tears, biceps rupture). MRI may show signal changes in the biceps tendon that indicate pathology.

Other Tests

• Diagnostic local anesthetic infiltration of the region of the bicipital groove may help clarify the source of the nociception. If an alternate diagnosis is suggested, other tests can be performed.
• Electromyography (EMG) or nerve conduction studies (NCS) are performed to rule out mononeuropathy, brachial plexopathy, or cervical radiculopathy.

TREATMENT

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Rehabilitation Program

Physical Therapy

The components of a physical therapy program are coordinated with various stages of the bicipital tendinopathy.

• Immediate
  • Initiate rest, ice, compression, and elevation (RICE) therapy.
  • Avoid activity that aggravates the condition.
• Subacute
  • Physical therapy should involve soft tissue therapy with transverse gliding of the tendon and cross-friction massage.
  • Electrical stimulation and/or ultrasonography may be beneficial if symptoms interfere with therapeutic exercise.
  • Apply moist heat to help facilitate stretching and reduce pain.
  • If the shoulder is stable, perform ROM exercises for the shoulder, including gradual stretching of the biceps tendon. Other activities include circumduction, pendulum, 2-hand rod swinging, and lateral/front finger wall walking.
  • Progress to resistive exercises as symptoms subside. Isometrics progress to concentric exercises, then eccentric exercises, and finally sport-specific exercises. Eccentric loading in the management of tendinopathies of other muscle groups has recently shown promise in reversing some degenerative changes (Rees, 2006).
  • Closed kinetic chain exercises are generally started first, with open kinetic chain exercises initiated later with sport-specific activities.
  • Perform proprioceptive shoulder exercises with a Swiss ball.
  • Address biomechanical factors that may be contributing to the biceps tendinopathy.
• Long term
  • Continue physical therapy as described.
  • Avoid aggravating factors.
  • Look for other causes or predisposing factors, such as bony abnormalities, labral pathology, and radiculopathy.

Occupational Therapy

The occupational therapist should instruct the patient in use of appropriate adaptive equipment, work simplification strategies, ergonomic modifications, stretching of appropriate shoulder girdle musculature, and an eventual strengthening program.

Medical Issues/Complications

Possible complications that develop from biceps tendinopathy include the following:

• Recurrent anterior shoulder pain
• Biceps rupture
• Weakness
• Maladaptive compensation strategies by the individual, causing other ailments

Surgical Intervention

• Surgery is rarely necessary, but it may be required in patients with refractory cases associated with persistent pain that has not responded to any other treatments.
• Surgery often involves decompression of the musculotendinous structure through tenolysis using arthroscopic or open surgical technique.

Other Treatment

• Injection with anesthetic and corticosteroid into the biceps tendon sheath may be helpful. This can be performed under ultrasound guidance to ensure correct placement of the medication. Avoid direct injection into the biceps tendon.
• Myofascial trigger point injections in the scapular stabilizer muscles may be beneficial. This technique uses an injection with dilute local anesthetic.
• Manipulation may be helpful, especially for first rib abnormalities that contribute to the syndrome.
• Lithotripsy (extracorporeal shock wave therapy) is under study for Achilles and patellar tendinopathy; the results are promising thus far. No studies related to biceps tendinopathy have been published.

MEDICATION

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Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to manage acute symptoms of pain and stiffness. No apparent advantage is noted of one agent over the other. Liniments, including NSAID and capsaicin creams, may be considered. Acetaminophen may be used for analgesia.

Drug Category: Nonsteroidal anti-inflammatory drugs

Most commonly used for relief of mild to moderate pain. Although effects in treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include fenoprofen, flurbiprofen, mefenamic acid, ketoprofen, indomethacin, and piroxicam. Celebrex, a COX-2, inhibitor may also be used, although efficacy is not greater. An improved adverse effect profile is controversial.

Drug Name	Naproxen (Anaprox, Naprelan, Naprosyn)
Description	For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.
Adult Dose	375-500 mg PO bid
Pediatric Dose	<2 years: Not recommended >2 years: 10 mg/kg/d PO in divided doses
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Probenecid may increase toxicity; coadministration with ibuprofen may decrease effects of loop diuretics; coadministration with anticoagulants may prolong PT (watch for signs of bleeding); NSAIDs may increase serum lithium levels and risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in patients with syndrome of ASA, nasal polyps, and asthma; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug

Drug Name	Ketoprofen (Oruvail, Orudis, Actron)
Description	For relief of mild to moderate pain and inflammation. Small dosages are indicated initially in patients with small body size, elderly patients, and those with renal or liver disease. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	<3 months: Not established 3 months to 12 years: 0.1–1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity of NSAIDs
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Name	Celecoxib (Celebrex)
Description	Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared to nonselective NSAIDs. Seek lowest dose for each patient. Neutralizes circulating myelin antibodies through anti-idiotypic antibodies; down-regulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%). Has a sulfonamide chain and is primarily dependent upon cytochrome P450 enzymes (a hepatic enzyme) for metabolism.
Adult Dose	200-400 mg/d PO qd or divided bid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	CYP450 2C9 substrate; coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Pregnancy	X - Contraindicated in pregnancy
Precautions	May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; caution in severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or lab results suggest liver dysfunction

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients with tendinitis.

Drug Name	Capsaicin (Dolorac, Capsin, Zostrix)
Description	Derived from plants of Solanaceae family. May render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons.
Adult Dose	Cream: Apply to skin tid/qid for 3-4 consecutive wk and evaluate efficacy (not to exceed 4 applications/d)
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity; broken or irritated skin
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	For external use only; avoid contact with eyes; do not use tight bandage; discontinue use if condition worsens or symptoms persist for 14-28 d

FOLLOW-UP

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• Follow-up
• Miscellaneous
• Multimedia
• References

Deterrence/Prevention:

• Modify risk factors where possible.
• Strengthen muscles concentrically and eccentrically prior to return to full activity.
• Perform sport-specific or work-specific training prior to returning to work or sports activity.

Complications:

• Biceps rupture: The long head of the biceps is vulnerable to rupture.

Prognosis:

• Full recovery and return to work/sports are expected with 6-8 weeks.

Patient Education:

• Educate the patient about using proper body mechanics to prevent recurrent injury (eg, pitching techniques, lifting techniques). Advocate regular stretching before and after exercise.
• For excellent patient education resources, visit eMedicine's Arthritis Center and Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Tendinitis.

MISCELLANEOUS

Section 9 of 11  

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• Introduction
• Clinical
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• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Incorrect diagnosis
• Rupture of the long head of the biceps due to weakening caused by corticosteroid injection

Special Concerns

• Avoid injection of corticosteroid directly into the biceps tendon, as it may cause tendon weakening and subsequent rupture. Instead, only inject into the tendon sheath, not into the tendon.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  The Speed test: The examinee is pointing to where the pain usually is produced for a positive test.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
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• Miscellaneous
• Multimedia
• References

• Agur AM. Grant's Atlas of Anatomy. 9th ed. Baltimore, MD: Williams & Wilkins Publishing;. 1991: 408.
• Andrews J. Physical Rehabilitation of the Injured Athlete. 2nd ed. Philadelphia, PA: WB Saunders;. 1998: 478-573.
• Armstrong A, Teefey SA, Wu T, et al. The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder Elbow Surg. Jan-Feb 2006;15(1):7-11.
• Barber DB, Janus RB, Wade WH. Neuroarthropathy: an overuse injury of the shoulder in quadriplegia. J Spinal Cord Med. Jan 1996;19(1):9-11. [Medline].
• Brotzman S. Clinical Orthopaedic Rehabilitation. St Louis, MO: Mosby Publishing. 1996: 82, 95.
• Cailliet R. Shoulder Pain. Philadelphia, PA: FA Davis Publishing;. 1991: 3, 4, 46-50, 114-6.
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• Fisk C. Adaptation of the technique for radiography of the bicipital groove. Radiol Technol. Sep 1965;37:47-50.
• Frontera WR, Silver JK. Essentials of Physical Medicine and Rehabilitation. Philadelphia, PA: Hanley & Belfus. 2002;67-71.
• Jenkins D. Hollinshead's Functional Anatomy of the Limbs and Back. Philadelphia, PA: WB Saunders;. 1991: 110-1, 115-6, 149, 150.
• Larson HM, O''Connor FG, Nirschl RP. Shoulder pain: the role of diagnostic injections. Am Fam Physician. Apr 1996;53(5):1637-47. [Medline].
• Mellion M. Sports Medicine Secrets. St. Louis, MO: Hanley, Belfus and Mosby Publishing;. 1990: 244-9.
• Pfahler M, Branner S, Refior HJ. The role of the bicipital groove in tendopathy of the long biceps tendon. J Shoulder Elbow Surg. Sep-Oct 1999;8(5):419-24. [Medline].
• Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford). May 2006;45(5):508-21.
• Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg. Nov-Dec 1999;8(6):644-54. [Medline].
• Smith DL, Campbell SM. Painful shoulder syndromes: diagnosis and management. J Gen Intern Med. May-Jun 1992;7(3):328-39. [Medline].
• Travel J, Simons D, Simons L. Myofascial Pain and Dysfunction. 2nd ed. Baltimore, MD: Williams and Wilkins Publishing;. 1999: 649-658.
• Veldman PH, Goris RJ. Shoulder complaints in patients with reflex sympathetic dystrophy of the upper extremity. Arch Phys Med Rehabil. Mar 1995;76(3):239-42. [Medline].
• Wober W, Rahlfs VW, Buchl N, et al. Comparative efficacy and safety of the non-steroidal anti-inflammatory drugs nimesulide and diclofenac in patients with acute subdeltoid bursitis and bicipital tendinitis. Int J Clin Pract. Apr-May 1998;52(3):169-75. [Medline].

Article Last Updated: Jun 22, 2006