eMedicine Specialties > Sports Medicine > Upper Limb

Bicipital Tendonitis

Britt A Durham, MD, Director of Risk Management, Assistant Professor, Department of Emergency Medicine, King-Drew Medical Center and University of California at Los Angeles; CFO of Durcress Medical Group
Richard Chambers, MD, Chief of Orthopedic, Diabetes and Amputee Service, Clinical Associate Professor, Department of Orthopedic Surgery, Rancho Los Amigos Medical Center, University of Southern California
Contributor Information and Disclosures

Updated: Jan 4, 2008

Introduction

Background

Bicipital tendinitis, or biceps tendinitis, is an inflammatory process of the long head of the biceps tendon and is a common cause of shoulder pain due to its position and function.^{1, 2, 3, 4} The tendon is exposed on the anterior shoulder as it passes through the humeral bicipital groove and inserts onto the superior aspect of the labrum of the glenohumeral joint. Disorders of the biceps tendon can result from impingement or as an isolated inflammatory injury. Other causes are secondary to compensation for rotator cuff disorders, labral tears, and intra-articular pathology.

For excellent patient education resources, visit eMedicine's Arthritis Center and Sports Injury Center. Also, see eMedicine's patient education articles Tendinitis, Rotator Cuff Injury, and Repetitive Motion Injuries.

Frequency

United States

Bicipital tendinitis is frequently diagnosed in association with rotator cuff disease as a component of the impingement syndrome or secondary to intra-articular pathology, such as labral tears.
 
Related eMedicine topic:
Superior Labral Lesions

Related Medscape topic:
American Orthopaedic Society for Sports Medicine 31st Annual Meeting-NSAIDs and Physical Therapy Effective for Superior Labral Tears

Functional Anatomy

As its name implies, the biceps has 2 proximal heads with a common distal insertion onto the radius. The long head of the biceps merges with the short head of the biceps to form the body of the biceps brachii muscle. This muscle is a powerful supinator and flexor of the forearm.

The long head biceps tendon lies in the bicipital groove of the humerus between the greater and lesser tuberosities and angles 90° inward at the upper end of the groove, crossing the humeral head to insert at the upper edge of the glenoid labrum and supraglenoid tubercle. The long head of the biceps tendon helps to stabilize the humeral head, especially during abduction and external rotation.

Sport-Specific Biomechanics

Bicipital tendinitis frequently occurs from overuse syndromes of the shoulder, which are fairly common in overhead athletes such as baseball pitchers, swimmers, gymnasts, racquet sport enthusiasts (eg, tennis players), and rowing/kayak athletes.^{5, 6, 7} Trauma may occur because of direct injury to the biceps tendon when the arm is passed into excessive abduction and external rotation. This pattern of shoulder injury can also occur in the left shoulder of right-handed golfers. Many overuse injuries coexist with some degree of bicipital tendinitis and rotator cuff tendinitis.

The athletic shoulder differs qualitatively from the biomechanics of the shoulder in daily life because of the higher energies and repetitive motions that are involved in athletic activities. Sports activities that require repetitive overhead motion with inadequate reparative time may cause the biceps tendon to break down.

Clinical

History

• Patients typically complain of achy anterior shoulder pain, which is exacerbated by lifting or elevated pushing or pulling. A typical complaint is pain with overhead activity or with lifting heavy objects.
• Pain may be localized in a vertical line along the anterior humerus, which worsens with movement. Often, however, the location of the pain is vague, and symptoms may improve with rest.
• Most patients with bicipital tendinitis have not sustained an acute traumatic injury. However, partial traumatic biceps tendon ruptures have been described and may occur in combination with underlying tendinitis. Individuals with rupture of the long head of the biceps tendon may report a sudden and painful popping sensation. The retracted muscle belly bulges over the anterior upper arm, which is commonly described as the "Popeye" deformity. In patients without acute traumatic injuries, the biceps tendon rupture is usually preceded by a history of shoulder pain that quickly resolves after a painful audible snap occurs.
• Occasionally, shoulder instability and subluxation can be associated with biceps degeneration from chronic tendinitis, resulting in a palpable snap in a painful arc of motion that is seen in throwing athletes. Superior labral tears (superior labrum anterior and posterior [SLAP] lesions) may have similar findings, but these injuries are more prone to locking or catching symptoms.⁸

Physical

• Local tenderness is usually present over the bicipital groove, which is typically located 3 inches below the anterior acromion. The tenderness may be localized best with the arm in 10 º of external rotation.
• Flexion of the elbow against resistance aggravates the patient's pain.
• Passive abduction of the arm in an arc maneuver may elicit pain that is typical of impingement syndrome; however, this finding may be negative in cases of isolated bicipital tendinitis.
• Speed test: The patient complains of anterior shoulder pain with flexion of the shoulder against resistance, while the elbow is extended and the forearm is supinated.
• Yergason test: The patient complains of pain and tenderness over the bicipital groove with forearm supination against resistance, with the elbow flexed and the shoulder in adduction. Popping of subluxation of the biceps tendon may be demonstrated with this maneuver.
• The remainder of the examination should include evaluation and documentation of active and passive range of motion (ROM) and joint stability in order to assess the rotator cuff and glenoid labrum. A complete evaluation includes a complete neurovascular assessment.
• Bicipital tendinitis with labral tears or rotator cuff tears may not improve if all the conditions are not treated.

Causes

• The long head of the biceps tendon passes down the bicipital groove in a fibrous sheath between the subscapularis and supraspinatus tendons. This relationship causes the biceps tendon to undergo degenerative and attritional changes that are associated with rotator cuff disease because the biceps tendon shares the associated inflammatory process within the suprahumeral joint.
• Full humeral head abduction places the attachment area of the rotator cuff and biceps tendon under the acromion. External rotation of the humerus at or above the horizontal level compresses these suprahumeral structures into the anterior acromion. Repeated irritation leads to inflammation, edema, microscopic tearing, and degenerative changes.
• In younger athletes, relative instability due to hyperlaxity may cause similar inflammatory changes on the biceps tendon due to excessive motion of the humeral head.
• Labral tears may disrupt the biceps anchor, resulting in dysfunction and causing pain.
• The transverse humeral ligament holds the biceps tendon long head within the bicipital groove. Injuries and disruption of the ligament can lead to subluxation and medial dislocation of the biceps tendon. Local edema and calcifications can physically displace the biceps tendon from the bicipital groove, resulting in subluxation. An osteochondroma in the bicipital groove has been reported as a cause of bicipital tendinitis in a baseball player by physical displacement and subluxation.⁹

Related eMedicine topic:
Osteochondroma and Osteochondromatosis

References

• Superior Labrum Lesions

• Arthritis Center
• Tendinitis Overview
• Tendinitis Causes
• Tendinitis Symptoms
• Tendinitis Treatment