BICEPS TENDONITIS
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related talks: rotator cuff tear; biceps tendon tear; adhesive capsulitis
What is Biceps Tendonitis?
Biceps tendonitis is inflammation and degeneration of the biceps tendon right before it attaches to your shoulder bone. Its a common cause of shoulder pain.
Lets quickly review the anatomy of your arm. The biceps is the "popeye muscle" (from the cartoon), located in the front of your arm, and it helps to flex your elbow and rotate your forearm. It got the name biceps because its actually made of two ("bi", like "bicycle") muscles that originate in the shoulder (glenoid rim, coracoid) and insert on the forearm (radial tuberosity).
Biceps tendonitis is actually a very common condition that affects people of all ages and levels of activity.
How is Biceps Tendonitis diagnosed?
Biceps Tendonitis is considered an overuse injury and is suspected in someone that reports gradually worsening shoulder pain without any recent trauma.
It can be a challenging condition to diagnose for doctors because the shoulder is a complex array of soft tissue that includes tendons, ligaments, the labrum. Any of these can be torn from a recent trauma or inflamed from months or years of overuse and gradual degeneration.
People typically report a dull aching, or burning pain in the front of their shoulder that has bothered them for weeks or months. Doctors have developed a series of physical exam tests which can help to isolate the affected tendon. People with biceps tendonitis typically have pain directly over the biceps tendon (surprise surprise) which is located in the front of the shoulder, and they have pain when asked to put their arm straight out (with the palm up) and hold it up against resistance.
X-rays are often ordered to rule out other causes of shoulder pain, like shoulder arthritis, however biceps tendonitis itself cannot be seen on x-ray. MRI is a better test for directly showing the inflammation, which is seeing as a thickening (swelling) of the tendon and surrounding fluid.
How is a Biceps Tendonitis treated?
Biceps tendonitis should be treated in a stepwise fashion starting from least invasive and progressing to more involved options if pain persists.
Initial treatment consists of physical therapy, using ice packs, taking antiinflammatory medication, and avoiding activities that make the pain worse.
If the pain continues, many doctors will offer a steroid injection around the tendon, which can provide quick relief by soothing the inflammation. The steroid should be injected around the tendon, not into the tendon itself. This treatment does have a small risk of causing the tendon to tear (rupture). Rupture of the tendon may cause a "popeye deformity", meaning that your bicep muscle will bunch up in the middle of your arm and look like its being flexed at all times. Rupturing the inflamed muscle is actually not the worst thing to happen...in fact rupturing the tendon is a form of surgical treatment called a "tenotomy", also called a "surgical release".
A Tenotomy is one of two common surgical procedures for this condition if all other treatments fail to relieve the pain. Sometimes the tendon is just too damaged to ever improve significantly and it will remain a pain-generator as long as its under tension. When "released" the tendon relaxes and the pain goes away.
The other surgical treatment is a Tenodesis, which is to release the tendon from its normal attachment, remove the degenerative and inflamed portion, and then re-attach the healthy tendon along the arm bone. This technique prevents the "popeye deformity" because the muscle is still held under some tension so it wont bunch up in the arm.
What is the long term outcome?
Treatment of this condition is usually effective, although some people need the more involved procedures like a tenotomy or tenodesis. The sooner the condition is treated the better chance that medication and therapy will provide effective pain relieve.
Prolonged inflammation (months or years of pain) cause degeneration in the tendon which rarely responds to anything less than surgery.
Reference
1) Nho SJ et al. Long head of the biceps tendinopathy: diagnosis and management. JAAOS 2010; 18: 645-56. full article. review.
2) Sethi N et al. Disorders of the long head of hte bicpes tendon. J Shoulder Elbow Surg 1999; 8: 644-54. full article. review
3) Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. JBJS Br 2007; 89: 1001-9. full article. biceps tendonitis often seen in conjunction with other shoulder path. sheath of the LHB tendon is continuous with the glenohumeral joint synovium.
4) Mohtadi NG et al. A prospective, double-blind comparison of magnetic resonance imaging and arthroscopy in the evaluation of patients presenting with shoulder pain. J Shoulder Elbow Surg 2004; 13: 258-265. full article. poor correlation between mri and arthroscopy: 60% agreement in shoulder, only 35% agreement for biceps path.
Treatment
5) Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the shoulder region. Am Fam Physician 2003; 67: 1271-78. full article. indications for steroid injection.
6) Hsu Ar et al. Biceps tenotomy versus tenodesis: a review of clniical outcomes and biomechanical results. J Shoulder Elbow Surg 2011; 20: 326-32. full article. tenotomy has worse cosmesis, tenodesis has higher chance of persistant postop pain.
7) Frost A et al. Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii. Am J Sports Med 2009; 37: 828-833. full article. systematic review. no functional difference between the two.
8) Kelly AM et al. Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results. Am J Sports Med 2005; 33: 208-13. full article. indications for surgery: LHB subluxation, 25-50% tear, hourglass/inflam appearance on diagnostic scope. 54 pts, 40% complained of fatigue discomfort postop, 70% popeye sign so best for elderly, but overall high satisfaction ASES score 77 avg. (pain relief)
9) Mazzocca AD et al. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy 2005; 21: 896. full article. distal fixation. reduces risk of postop pain from persist tendon within groove.
10) Boileau P, Neyton L. Arthrscopic tenoedsis for lesions of the long head of the biceps. Oper Ortho Trauma 2005; 17: 601-23. full article. 90% return strength. prox fixation.