AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

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

INTRODUCTION

Section 2 of 10  

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

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

Section 3 of 10  

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

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 10º 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

DIFFERENTIALS

Section 4 of 10  

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

Other Problems to Be Considered

Fracture of the greater or lesser tuberosity
Glenohumeral instability (humeral subluxation)
Glenoid labrum tear
Inflammatory arthropathy
Neoplasm
Peripheral nerve entrapment
Strain and tear of the subscapularis
Synovitis

See also the following on eMedicine:
Adhesive Capsulitis [in the Orthopedic Surgery section]
Adhesive Capsulitis [in the Physical Medicine and Rehabilitation section]
Bursitis [in the Orthopedic Surgery section]
Bursitis [in the Emergency Medicine section]
Multidirectional Glenohumeral Instability
Nerve Entrapment Syndromes [in the Neurology section]
Nerve Entrapment Syndromes of the Lower Extremity [in the Orthopedic Surgery section]
Peripheral Nerve Injuries
Posterior Glenohumeral Instability
Rotator Cuff Disease
Superior Labral Lesions [in the Orthopedic Surgery section]

Related Medscape topic:
Resource Center Arthritis 

WORKUP

Section 5 of 10  

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

Lab Studies

• Laboratory tests are usually not indicated in cases of bicipital tendinitis, except when considering systemic diseases in the differential diagnosis or when excluding the possibility of neoplasm.

Imaging Studies

• Radiographs
• • Standard shoulder radiographs are generally not helpful or necessary in cases of isolated bicipital tendinitis.
  • Plain radiographs with bicipital groove views may demonstrate calcifications in the groove; however, calcifications rarely alter treatment.
  • Radiographic studies of the neck and elbow may be necessary to exclude referred shoulder pain from these locations.
  • Radiographs are indicated in cases that are not isolated, do not respond to treatment, or in patients in which there is the clinical suspicion of or a history of neoplastic disease.
  • Subacromial spurring is often seen in impingement syndrome and is most visible on the outlet and anteroposterior impingement syndrome radiographic views.
• Magnetic resonance imaging (MRI)
• • This imaging study can demonstrate the entire course of the long head of the biceps tendon; however, MRI is expensive and not cost effective as a routine imaging test for bicipital lesions.
  • MRI should be considered after unsuccessful rehabilitation and in cases of suspected rotator cuff injury or labral tear injury.
• Ultrasound and arthrography
• • Some authors have described the use of ultrasound and arthrography to identify tendon lesions.^{10, 11}
  • Although ultrasound has the most variable results because it is operator dependent, newer technologies have resulted in improved visualization of the calcific deposits, edema, and tendon displacement that are often associated with bicipital tendinitis.¹²
• Arthroscopy^{13, 14}
• • Arthroscopy may be useful in evaluating chronic shoulder pain.
  • This procedure is sensitive for detecting and differentiating subtle defects in the shoulder, including lesions in the superior labral complex and the articular surface of the humeral head.
  • Arthroscopy should not be used as a diagnostic tool for bicipital tendinitis unless the patient is not responding to the usual effective treatment or if other lesions or diagnoses are considered. Arthroscopy evaluates the intra-articular portion of the long head of the biceps tendon and is generally not performed for diagnosis alone.
  • Arthroscopy is usually indicated when lesions of the biceps tendon occur with other diagnoses, such as tears of the labrum or rotator cuff and/or with intra-articular loose bodies.

Procedures

• Although not routinely used, a local anesthetic block in the bicipital groove may help the clinician to differentiate bicipital tendinitis from referred rotator cuff pain and glenohumeral joint disease. Use of steroids during this procedure can have long-term treatment value.¹⁵
• Judicious use of subacromial and/or glenohumeral joint steroid injections are recommended for persistent cases of bicipital tendinitis.^{1, 15} Note: Although injection into the biceps sheath is effective, injection into the tendon itself can result in biceps tendon degeneration and rupture.
• Ultrasonographic-guided percutaneous steroid injections have been described in the literature and may result in better placement with potentially less complications.

TREATMENT

Section 6 of 10  

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

Acute Phase

Rehabilitation Program

Physical Therapy

The initial goals of the acute phase of treatment for bicipital tendinitis are to reduce inflammation and swelling. Patients should restrict over-the-shoulder movements, reaching, and lifting.

Patients should apply ice to the affected area for 10-15 minutes, 2-3 times per day for the first 48 hours. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are used for 3-4 weeks to treat inflammation and pain. The degree of immobilization depends upon the degree of the injury and the patient's discomfort. Most authors agree that prolonged immobilization tends to result in a stiff shoulder.

Physical therapy plays a minor role in the treatment of acute bicipital tendinitis; however, some authors recommend daily weighted, pendulum stretch exercises for uncomplicated and mild cases of acute bicipital tendinitis. Use of transcutaneous electrical nerve stimulation (TENS) has been reported with some success.

Phonophoresis and iontophoresis are examples of methods that are used to deliver steroids into inflamed tissue without an injection. Phonophoresis uses ultrasound, whereas iontophoresis uses electrical repulsion to transport medicines through the skin. In order to deliver an effective steroid concentration, the target area should be superficial, and serial application is necessary.

Medical Issues/Complications

It is important to realize that performing analgesic and steroid injections into the bicipital groove is not without risk. Use care to avoid direct injection into the long head of the biceps tendon itself because this can result in direct trauma to—and may lead to atrophy and/or rupture of—the tendon. Other complications from injections include postinjection infection and inflammatory reaction. In order to exclude a possible missed differential diagnosis, radiographic imaging should be considered if no improvement occurs after treatment.

Consultations

Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.

Other Treatment

A local injection of an anesthetic and steroid can be given in the bicipital groove. A combination of 2-3 mL of anesthetic with 1 mL of methylprednisolone (Depo-Medrol; Pfizer Inc, New York, NY) is typically recommended 3-6 weeks after the acute injury. A repeat injection can be performed 4 weeks later if the symptoms have not decreased by 50%. Caution is indicated with additional injections or with patients older than 40 years because there is an increased risk of biceps tendon rupture from repetitive injections. Restrict lifting and overhead activities by the patient for 30 days after the injection.

Recovery Phase

Rehabilitation Program

Physical Therapy

Physical therapy and rehabilitation are directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint while restoring the affected shoulder's ROM, which is critical for most athletes.

The goal of the recovery phase is to achieve and maintain full and painless ROM. Weighted, pendulum stretch exercises are combined with isometric toning. These exercises are recommended 3 times per week throughout the recovery phase. Passive stretching with ROM exercises removes residual shoulder stiffness. The uninvolved shoulder can be used as a standard comparison to achieve symmetric ROM.

Occupational Therapy

Although a rehabilitation program should improve strength and flexibility, adding an interval program can help restore normal joint arthrokinematics. Interval tennis and baseball programs have been developed for highly competitive athletes as these individuals recover from bicipital tendinitis. The patient progresses in a series of steps and stages, with the goal of returning safely to competition without reinjury. The progression of therapy is dependent upon a gradual, painless increase in activity without excessive fatigue. 

Medical Issues/Complications

Failure to recognize concomitant injuries with bicipital tendinitis could result in delayed healing and damage from inappropriate treatment. Physical therapy for shoulder injuries or a misdiagnosed injury may aggravate other conditions in the elbow and neck.

Consultations

Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.

Other Treatment (Injection, manipulation, etc.)

Weighted, pendulum swings should begin with moist heat application to the shoulder on the affected side, followed by therapy with 5- to 10-lb weights, which are held lightly in the hand. The shoulder muscle should be relaxed and the arm kept vertical and close to the body. The arm is allowed to swing back and forth, no greater than 1 inch in any direction. Note: This exercise is not appropriate for patients who have shoulder separation or strain, upper back strain, or neck strain.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase concentrates on the patient developing increased strength and endurance on the affected side. This phase can begin as soon as patient discomfort is effectively controlled and should continue for at least 3 weeks after the pain has completely resolved. When performing strengthening exercises, it is safer for the individual to start out with low tension, followed by a gradual increase in force, because flare-ups can occur.

The patient continues isotonic and isokinetic stretching and is allowed limited participation in sports activities. Monitor the patient and adjust his/her activities as progress allows. Note: Conditioning and proper throwing techniques are important for certain athletes because improper mechanics may result in tissue fatigue and damage.

Surgical Intervention

Surgical intervention is not recommended for bicipital tendinitis if the patient is making a slow and gradual improvement. Surgical treatment is only indicated after a 6-month trial of conservative care is unsuccessful. Although good results have been reported with arthroscopic decompression, acromioplasty with anterior acromionectomy is the standard surgical treatment for bicipital tendinitis. The biceps tendon does not generally undergo tenodesis unless severe attritional wear or eminent rupture is found.^{7, 16} No attempt is made to repair biceps tendon ruptures older than 6 weeks.

Tenodesis is not recommended when it is believed that the tendinitis is reversible. Specific indications for tenodesis of the biceps long head include the following^{7, 16}:

• Greater than 25% partial-thickness biceps tendon tear
• Severe subluxation from the bicipital groove
• Disruption of the associated bony or ligamentous anatomy of the groove itself
• Biceps tendon atrophy greater than 25%
• Failure of surgical decompression

Growing evidence has shown a shift from routine tenodesis to a more individual approach, with considerations such as physiologic age, activity level, expectations, and specific combinations of shoulder pathology as important factors.⁷ Although new repair techniques continue to be developed, the preference is for preservation of the biceps-labral complex rather than routine surgery. When surgery is performed for bicipital tendinitis, the procedure is typically performed through an open anterior incision. Variations of this surgery include arthroscopic techniques and open exposures with suture anchors through the subclavian portal.

Consultations

Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.

MEDICATION

Section 7 of 10  

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

The goals of pharmacotherapy are to reduce patient morbidity and prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are anti-inflammatory and non-narcotic medications that have analgesic and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions. The treatment of pain tends to be patient specific.

Drug Category: Local anesthetics

Local anesthetics block the generation of conduction impulses in a nerve, thereby preventing the transmission of pain.

Drug Category: Glucocorticoids

Glucocorticoids stimulate synthesis of enzymes that decrease inflammatory responses and suppress the immune system.

FOLLOW-UP

Section 8 of 10  

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

Return to Play

Return to activity should not occur until the patient's discomfort and pain is controlled effectively and a monitoring program has been initiated. Some authors recommend waiting 3 weeks after pain has completely resolved before allowing participation in competitive activities.

Complications

Individuals who return to a high level of athletic activity too soon may find themselves with symptom flare-ups. Continued straining of an injury that has not healed completely can put the individual at risk for chronic degenerative tissue damage and biceps tendon rupture.

Prevention

Prevention of bicipital tendinitis is similar to prevention of rotator cuff injuries, including warm-ups before exercise, the use of passive stretching and strengthening exercises, avoidance of painful activities, and the use of proper biomechanics. Increased attention should be made for those athletes at high risk of bicipital tendinitis, such as baseball pitchers. High angular velocity and torques combined with the repetitious nature of pitching results in vulnerability of the shoulder to injury.

Prognosis

Although the prognosis of bicipital tendinitis is dependent upon the degree of injury, most patients do well with treatment (see Treatment: Acute Phase, Recovery Phase, Maintenance Phase, and Surgical Intervention). However, a significant number of patients develop degenerative changes, and spontaneous rupture of the biceps tendon occurs in 10% of patients.

Education

Inform the patient that an increased risk of biceps tendon rupture or chronic inflammatory changes exists if the directed restrictions are not followed.

MISCELLANEOUS

Section 9 of 10  

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

Medical/Legal Pitfalls

• The risks and benefits of therapy as well as alternative treatments and procedures should be discussed with patients in advance. Although most individuals easily tolerate a rupture of the biceps tendon, an athlete could lose a competitive edge in his/her sport.
• Failure to advise patients of the increased risk of (1) a biceps tendon rupture from the direct trauma of an accidental steroid injection into the tendon or (2) atrophy that results from multiple injections may place the physician at risk because of failure to obtain appropriate written informed consent.
• Failure to recognize bicipital tendinitis may result in tendon rupture or chronic degenerative changes, which theoretically could be preventable with appropriate therapy.
• Tennis players are an example of athletes who often present with simultaneous injuries. As many as one third of tennis players who present with shoulder injuries have additional pathology in the ipsilateral elbow and the neck. Failure to modify physical therapy and medical treatment to take these concomitant conditions into consideration may aggravate the coexisting injuries. Likewise, misdiagnosis may result in the use of therapy that may exacerbate other lesions and also create a delay in the appropriate treatment.

Special Concerns

• Patients who are receiving repetitive injections and those who are older than 40 years are at an increased risk of complications. Inform the patient of these potential complications before performing any procedures.

REFERENCES

Section 10 of 10

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

1. Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. Aug 2007;89(8):1001-9. [Medline].
2. Safran MR, McKaeg DB, Van Camp SP, eds. Biceps tendon injuries. Manual of Sports Medicine. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998:347-9.
3. Nicholis JA, Hershman EB, eds. Bicipital tendinitis. The Upper Extremity in Sports Medicine. 2^nd ed. St. Louis, Mo: Mosby; 1995:303-6.
4. Rockwood CA Jr, Matsen FA II, eds. The Shoulder. Philadelphia, Pa: WB Saunders; 1990:810-21.
5. Ouellette H, Labis J, Bredella M, et al. Spectrum of shoulder injuries in the baseball pitcher. Skeletal Radiol. Oct 3 2007;Epub ahead of print. [Medline].
6. Park SS, Loebenberg ML, Rokito AS, Zuckerman JD. The shoulder in baseball pitching: biomechanics and related injuries -- part 1. Bull Hosp Jt Dis. 2002-2003;61(1-2):68-79. [Medline]. [Full Text].
7. Patton WC, McCluskey GM 3rd. Biceps tendinitis and subluxation. Clin Sports Med. Jul 2001;20(3):505-29. [Medline].
8. Holtby R, Razmjou H. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. Mar 2004;20(3):231-6. [Medline].
9. Onga T, Yamamoto T, Akisue T, Marui T, Kurosaka M. Biceps tendinitis caused by an osteochondroma in the bicipital groove: a rare cause of shoulder pain in a baseball player. Clin Orthop Relat Res. Feb 2005;431:241-4. [Medline].
10. Papatheodorou A, Ellinas P, Takis F, et al. US of the shoulder: rotator cuff and non-rotator cuff disorders. Radiographics. Jan-Feb 2006;26(1):e23. [Medline]. [Full Text].
11. Lecoq B, Levasseur R, Fournier L, Schmutz G, Marcelli C. Atypical pattern of acute severe shoulder pain: contribution of sonography. Joint Bone Spine. Nov 2004;71(6):592-4. [Medline].
12. Ardic F, Kahraman Y, Kacar M, et al. Shoulder impingement syndrome: relationships between clinical, functional, and radiologic findings. Am J Phys Med Rehabil. Jan 2006;85(1):53-60. [Medline].
13. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford). May 2006;45(5):508-21. [Medline]. [Full Text].
14. Ellman H, Gartsman GM. Arthroscopic Shoulder Surgery and Related Procedures. Philadelphia, Pa: Lea & Febiger; 1993:243-4.
15. Skedros JG, Hunt KJ, Pitts TC. Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians. BMC Musculoskelet Disord. 2007;8:63. [Medline]. [Full Text].
16. 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].
17. Ellenbecker TS. Rehabilitation of shoulder and elbow injuries in tennis players. Clin Sports Med. Jan 1995;14(1):87-110. [Medline].
18. Kim KC, Rhee KJ, Shin HD, Kim YM. A SLAP lesion associated with calcific tendinitis of the long head of the biceps brachii at its origin. Knee Surg Sports Traumatol Arthrosc. Dec 2007;15(12):1478-81. [Medline].
19. Longo UG, Franceschi F, Ruzzini L, et al. Characteristics at haematoxylin and eosin staining of ruptures of the long head of the biceps tendon. Br J Sports Med. Dec 10 2007;Epub ahead of print. [Medline].
20. Murtagh J. Bicipital tendinitis. Aust Fam Physician. Jun 1991;20(6):817. [Medline].
21. Shiri R, Varonen H, Heliövaara M, Viikari-Juntura E. Hand dominance in upper extremity musculoskeletal disorders. J Rheumatol. May 2007;34(5):1076-82. [Medline].
22. van Tulder M, Malmivaara A, Koes B. Repetitive strain injury. Lancet. May 26 2007;369(9575):1815-22. [Medline].

Article Last Updated: Jan 4, 2008