Biceps Tendinopathy

Definition/Description

Proximal biceps tendinopathy is the inflammation of the tendon around the long head of the biceps muscle. Acute biceps tendinopathy may occur because of sudden overuse, especially among athletic patients aged over 35 and any patient aged over 65. For shoulder pain patients, biceps tendinopathy can be one of numerous etiologies and frequently accompanies other pathologies of the shoulder.[1]

[2]

Clinically Relevant Anatomy

Biceps-brachii.jpg

Biceps brachii is innervated by the musculocutaneus nerve (C5, C6 and C7). It flexes and supinates the forarm as well its primary role of elbow flexion. It also has a very important role in the stabilization of the humerus in the cavitas glenoidalis.

The biceps has two proximal attachments:

  • Caput longum: originates from the supraglenoid tubercle of the scapula and crosses over the head of the humerus within the glenohumeral joint cavity, which is the intra-articular portion. The tendon then descends down the humerus via the intertubercular sulcus while encased in a synovial membrane, which is the extra-articular portion. The transverse humeral ligament helps secure the tendon in place by running from the greater to the lesser tubercle, creating a canal-like structure over the intertubercular groove, as well as the biceps pulley or “sling” which is a capsuloligamentous complex composed of the superior glenohumeral ligament, the coracohumeral ligament, and the distal attachment of the subscapularis tendon. The tendon of the caput longum slides passively on the humeral head during abduction or rotation, in the active state it only contributes for 10% of the power for abduction with the arm in external rotation ( which is a not common movement in ADL).[3][4]
  • Caput breve: The short head of the biceps begins at the tip of the coracoid process of the scapula and is not usually susceptible to tendonitis.

Other structures that lie in close contact with the biceps tendon include the anterior and posterior portions of the glenoid labrum and fibers of the subscapularis and supraspinatus tendons[3]. The long head of the biceps tendon also acts as a stabiliser for the antero-superior portion of the rotator cuff, as well as aiding the rotator cuff in maintaining an intimate relationship between the humeral head and the glenoid fossa[4].

The close articulation of the long head of the biceps tendon to other structures around the glenohumeral joint make it likely to be associated with rotator cuff and labral pathologies.[3]

Mechanism of Injury / Pathological Process

Previous studies have listed the following biomechanical causes for biceps tendinopathy:

  1. Coracoacromial ligament thickening,
  2. Impingement in the sub-acromial space
  3. Acromial apophysis fusion
  4. Rotator cuff tears, particularly those that involve the subscapularis tendon[4]
  5. Persistent rotator cuff tears (> 3 months)[5]

These pathologies can lead to biceps tendinopathy due to the repeated trauma by overuse and improper biomechanical circumstances movement patterns.[1]

As the long head of the biceps tendon rests encased in its synovial sheath within the intertubercular sulcus of the humerus, the transverse humeral ligament covering this sulcus can rupture, causing it to slide back and forth, leading to a wear and tear effect on the long head of the biceps tendon. Repetitive microtrauma (commonly seen in overhead-throwing or racquet athletes) can also lead to inflammation of the tendon.[1]

This repetitive inflammation can lead to tendon degeneration and therefore a weakness in the tendon causing pain and reduced function as classically seen with other types of tendinopathy.[6]

Bicipital tendinopathy may be related to shoulder laxity and instability. Tendinopathy at the proximal end of the biceps may be related to traction overload tendinopathy. The biceps long head acts as a humeral stabilizer as well as a decelerator of elbow extension. When there is increased translation of the humeral head with activities, more stress is placed on the biceps and ligamentous structures. Activities that include repeated shoulder abduction with external rotation such as throwing may result in impingement of the biceps tendon in the bicipital groove beneath. Some possible causes of discomfort that have been observed with ultrasound include synovitis or effusion of the bicipital groove, mineralization of the transverse ligament, subluxing biceps tendon, and cyst of the tendon.

Inflammation of the biceps tendon within the intertubercular (bicipital) groove is called primary biceps tendinopathy, which occurs in 5 percent of patients with biceps tendinopathy. The 95 percent of patients without primary biceps tendinopathy usually have an accompanying rotator cuff tear or a tear of the superior labrum anterior to posterior, known as a SLAP lesion. Pathology of the biceps tendon is most often found in patients 18 to 35 years of age who are involved in sports, including throwing and contact sports, swimming, gymnastics, and martial arts. These patients often have secondary impingement of the biceps tendon, which may be caused by scapular instability, shoulder ligamentous instability, anterior capsule laxity, or posterior capsule tightness. Secondary impingement may also be caused by soft tissue labral tears or rotator cuff tears that expose the biceps tendon to the coracoacromial arch.[7]

The relationship between intertubercular sulcus integrity and biceps tendinopathy has been controversial in the literature. Recent evidence shows that MRI-measured morphology of the intertubercular sulcus is not a significant predictor of either biceps tendinopathy or a rotator cuff pathology[8].

Overall, biceps tendinopathy is likely to present with associated shoulder pathologies, such as subacromial impingement, rotator cuff tears, instability or tensile injury. The injury cascade of shoulder impingement resulting in rotator cuff injury is a common sequelae that often leads to long head of the biceps tendon involvement[4].

Clinical Presentation/ Characteristics

Patients will typically report an insidious onset of discomfort around the region of the involved tendon.[5] Patients with biceps tendinopathy often complain of a deep, throbbing pain in the anterior shoulder that is intensified when lifting. The pain is usually localised to the bicipital groove and might radiate toward the insertion of the deltoid muscle.[1]

This makes it difficult to distinguish from pain that is secondary to impingement or tendinopathy of the rotator cuff, or cervical spine pathology. Pain from biceps tendinopathy usually worsens at night, especially if the patient sleeps on the affected shoulder.[7] Pain may be aggravated by overhead reaching, pulling, lifting and repetitive activities..[4]

Active elbow flexion may also provoke pain; however, weakness associated with elbow flexion may not be a reliable measure for assessing the presence of biceps tendinopathy, as this motion involves contraction of the short head of the biceps brachii and the brachioradialis muscles.[4]

In cases associated with biceps instability, the patient may complain of an anterior shoulder “clicking” or “popping” sensation that may or may not be associated with throwing motions.[9]

Differential Diagnosis

Differential Diagnosis of Anterior Shoulder Pain:[7]

Diagnostic Procedures

Subjective Assessment

Due to the lack of specificity in differentiating between biceps tendon pathology, subacromial impingement syndromes, and rotator cuff pathology, it is important to take an extensive history upon evaluation and not use these tests solely to make a diagnosis[3]

Objective Assessment

Palpation

Pain with palpation over the bicipital groove (which is most felt in 10° of internal rotation) is a common physical finding for patients with biceps tendinopathy.[3][7][4][5]

Range of Movement (ROM)

Testing of cervical, shoulder and elbow AROM should all be completed as well as PROM of shoulder and elbow.

Strength Testing

Strength testing of shoulder, elbow and wrist should all be completed to ensure no significant weakness of other structures. There may also be associated rotator cuff weakness due to the high prevalence of shoulder injuries accompanying biceps tendinopathy.

Provocative tests:

If any of these tests is positive, it indicates that impingement is present, which can lead to biceps tendinopathy.

No validated cluster of diagnostic tests is currently available for ruling in or out biceps tendinopathy specifically[7]. Therefore, these tests should be used to help guide the diagnosis:

  • Yergasons test: Yergason's test requires the patient to place the arm at his or her side with the elbow flexed at 90 degrees, and supinate against resistance. The test is considered positive if pain is referred to the bicipital groove.
  • Neers test: involves internal rotation of the arm while in the forward flexed position. If the patient experiences pain, it is a positive sign of shoulder impingement syndrome or sub acromial pain syndrome.
  • Hawkins test: the patient flexes the elbow to 90 degrees while the physician elevates the patient's shoulder to 90 degrees and places the forearm in a neutral position. With the arm supported, the humerus is rotated internally. The test is positive if bicipital groove pain is present.
  • Speeds test: the patient tries to flex the shoulder against resistance with the elbow extended and the forearm supinated. A positive test is pain radiating to the bicipital groove..[2][14][1]

Imaging

  • Arthrography
  • Bicipital groove view radiography
  • MRI
  • Radiography
  • Ultrasonography: is a good way to evaluate isolated tendinopathy extra-articulatory, which is also the most cost effective.[1] [3]

The diagnostic criteria for biceps tendinopathy were defined as meeting at least one of the following:

  1. Tendon sheath swelling (transverse view: for women ≥4.6, for men ≥5.5!mm;longitudinal view: for women ≥2.5, for men ≥2.8!mm, as adopted from Schmidt et al.)
  2. Tendon sheath fluid accumulation (abnormal hypoechoic or anechoic accumulation relative to the subdermal fat, although occasionally this could be isoechoic or hyperechoic) in intraarticular material that is displaceable and compressible and ≥3!mm, as adopted from Bruyn etal. In addition to the diagnostic criteria, increased color flow signals were recognized around the swollen biceps tendon as essential to a biceps tendinopathy diagnosis.

All involved with the musculoskeletal US examination reached a consensus on these diagnostic criteria for the purpose of avoiding operator-dependent misdiagnosis.[1]

Outcome Measures

Main outcome measures of biceps tendinopathy are:

  1. DASH (disabilities of the Arm, Shoulder and Hand) scoring,
  2. Range of motion,
  3. VAS/NPRS
  4. Simple Shoulder Test[10]

Medical Management

Conservative

Initial treatment should consist of pain management and use of NSAIDs. If this is unsuccessful the use of steroid injections may be helpful in managing pain. [11][12] Or for more persistent presentations, corticosteroid injections along the tendon sheath may be indicated.[4] In low-functioning or medically complicated patients, conservative measures should always be pursued initially.[11]

Surgical

If conservative management has not been successful then surgical management can be considered. This is indicated in higher functional level patients or athletes with extensive active pathology accompanied with other shoulder pathology such as rotator cuff tears.

Normally a biceps tenotomy or tenodesis is performed either via arthroscopic or open incisions. [11][12][6]

Surgical management of biceps tendinitis includes removing the long head of the biceps tendon via arthroscopic tenodesis. Research has shown this to provide sufficient reductions in pain levels while maintaining normal biceps function.[7]

Physical Therapy Management

Physical therapy has been commonly used for the treatment of tendinopathies: initially focusing on unloading followed by reloading the effected tendon (see Tendinopathy rehab page for full details).

This may start with isometric training if pain is the primary issue progressing into eccentric training and eventually concentric loading as with other forms of tendon rehab.

Stretching and strengthening programs are a common component of most therapy programs. Therapists also use other modalities, including ultrasound, iontophoresis, deep transverse friction massage, low-level laser therapy, and hyperthermia; however evidence for these modalities are has low quality.[13]

The physical therapist must consider both the patient's subjective response to injury and the physiological mechanisms of tissue healing; both are essential in relation to a patients return to optimal performance.

As a preface to discussion of the goals of treatment during injury rehabilitation, two points must be made:

  1. Healing tissue must not be overstressed and a very slow heavy loading program should be undertaken. During tissue healing, controlled therapeutic stress is necessary to optimize collagen matrix formation, but too much stress can damage new structures and slow the patient’s rehabilitation
  2. The patient must meet specific objectives to progress from one phase of healing to the next. These objectives may depend on ROM, strength, or activity. It is the responsibility of the physical therapist to establish these guidelines.[14]

Exercise therapy should include:

  1. Restoring a pain free range of motion - Pain free range can be achieved with such activities as PROM, Active-Assisted Range of Motion (AAROM), and mobilization via manual therapy
  2. Proper scapulothoracic rhythm.[12] .
  3. Painful activities such as abduction and overhead activities should be avoided in the early stages of recovery as it can exacerbate symptoms[12].
  4. Strengthening program consisting of heavy slow loading should begin with emphasis on the scapular stabilizers, rotator cuff and biceps tendon[14].

Resources

Biceps rehab protocol

Clinical Bottom Line

Biceps tendinopathy is an inflammation that can be caused by the normal ageing process as well by a degenerative process which usually occurs in athletes with repetitive overhead movements. It is important to understand, that this inflammation has many different causes and is frequently accompanied by other shoulder pathologies such as: SLAP-lesions, rotator-cuff tears or instability.

The patient will primarily experience pain localised in the bicipital groove and may radiate toward the insertion of the deltoid muscle, or down to the hand in radial distribution. Leading to an increase in pain on pull, push and overhead motions.

The best way to diagnose biceps tendinopathy, is by comparative palpation of the biceps tendon along the intertubercular groove, or otherwise by doing a ultrasonography (extra-articulair).

Treatment consists of conservative or surgical treatment. Surgery should be considered if conservative measures fail after three months. Structures causing primary and secondary impingement may be removed, and the biceps tendon may be repaired if necessary.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Huang SW, Wang WT. Quantitative diagnostic method for biceps long head tendinitis by using ultrasound. The Scientific World Journal. 2013;2013.
  2. Clinical Physio. Classic Long Head of Biceps Tendinopathy. Available from: https://www.youtube.com/watch?v=j4vYM7JXSW8 [Last accessed 25/10/2015]
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. The Journal of bone and joint surgery. British volume. 2007 Aug;89(8):1001-9.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Nakata W, Katou S, Fujita A, Nakata M, Lefor AT, Sugimoto H. Biceps pulley: normal anatomy and associated lesions at MR arthrography. Radiographics. 2011 May 4;31(3):791-810.
  5. 5.0 5.1 5.2 Salim M. Hayek,Binit J. Shah,Mehul J. Desai,Thomas C. Chelimsky. (2015) Pain Medicine An Interdisciplinary Case-Based Approach. OUP USA
  6. 6.0 6.1 Snyder GM, Mair SD, Lattermann C. Tendinopathy of the long head of the biceps. InRotator Cuff Tear 2012 (Vol. 57, pp. 76-89). Karger Publishers.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 2009 Sep 1;80(5):470-6.
  8. Taylor SA, Hannafin JA. Evaluation and management of elbow tendinopathy. Sports Health. 2012 Sep;4(5):384-93.
  9. 9.0 9.1 Park SS, Loebenberg ML, Rokito AS, Zuckerman JD. The shoulder in baseball pitching: biomechanics and related injuries--Part 1. Bulletin of the NYU Hospital for Joint Diseases. 2002 Dec 22;61(1-2):68-.
  10. Biz C, Vinanti GB, Rossato A, Arnaldi E, Aldegheri R. Prospective study of three surgical procedures for long head biceps tendinopathy associated with rotator cuff tears. Muscles, ligaments and tendons journal. 2012 Apr;2(2):133.
  11. 11.0 11.1 11.2 Longo UG, Loppini M, Marineo G, Khan WS, Maffulli N, Denaro V. Tendinopathy of the tendon of the long head of the biceps. Sports medicine and arthroscopy review. 2011 Dec 1;19(4):321-32.
  12. 12.0 12.1 12.2 12.3 Nho SJ, Strauss EJ, Lenart BA, Provencher MT, Mazzocca AD, Verma NN, Romeo AA. Long head of the biceps tendinopathy: diagnosis and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2010 Nov 1;18(11):645-56.
  13. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical orthopaedics and related research. 2008 Jul 1;466(7):1539-54.
  14. 14.0 14.1 Thomas R. Baechle.(2008) Essentials Of Strength Training And Conditioning. (third edition). National Strength and Conditioning Association. Human kinetic