Biceps Tendonitis

Jonathan D. Hodax M.S., M.D.
Andrew D. Sobel, M.D.

Basic Information

Definition

Inflammation or irritation of the tendon of the long head of the biceps brachii during its intraarticular course or its course within the proximal bicipital groove in the shoulder is a frequent cause of shoulder pain. The tendon originates from the glenoid and has attachments to the glenoid labrum, passes intraarticularly, and enters the biceps groove between the greater and lesser tuberosities of the proximal humerus (Fig. E1). Degeneration of the tendon may be due to repetitive stress, such as in overhead-throwing athletes, or may result from cumulative effects of traction, friction, shear, and compression of the tendon over time.

FIG.E1

Anatomic location of the long head of the biceps tendon with surrounding structures of the shoulder.

From Roberts JR, et al.: *Clinical procedures in emergency medicine,* ed 5, Philadelphia, 2009, Saunders.

Synonyms

Bicipital tendonitis
Bicipital tenosynovitis
Biceps tendinosis

ICD-10CM CODES
M75.20	Bicipital tendinitis of unspecified shoulder
M75.21	Bicipital tendinitis of right shoulder
M75.22	Bicipital tendinitis of left shoulder

Epidemiology & Demographics

Prevalence of degenerative biceps tendinopathy in older adults is approximately 0.5 per 100,000 in a 5-year period.
Degenerative tendinopathy is more common in male patients than in female patients, at a ratio of 3:1.
41% of complete rotator cuff tears have concomitant biceps tendonitis.

Risk Factors

Athletes involved in throwing sports, swimming, contact sports, weight lifting, gymnastics, and martial arts are at higherrisk, as well as nonathletes performing repetitive overhead movements such as carpenters, electricians, and mechanical wheelchair users.

Physical Findings & Clinical Presentation

Biceps tendinopathy is associated with additional shoulder pathology more often than it presents as an isolated pathology, and therefore the diagnosis can be challenging.

Patients typically complain of progressively worsening pain over the anterior shoulder.
Pain may radiate from the anterior shoulder down the anterior arm.
In some patients, the tendon may subluxate or dislocate from the bicipital groove, which is often felt as an uncomfortable “click” in the anterior shoulder.
Point tenderness over the bicipital groove is commonly present, especially with 10 degrees of internal rotation of the shoulder.
A positive Yergason test (pain with resisted supination with the elbow at 90°) is suggestive.
A positive Speed test (pain in the bicipital groove on resisted forward flexion of the arm with the palm up and the elbow straight with resolution with the palm down) is suggestive.
Uppercut and bear-hug tests may also increase the sensitivity of diagnosis.
A “Popeye” sign (distal migration and bunching of the biceps muscle) suggests rupture of the tendon (Fig. E2).

FIG.E2

Popeye deformity after a biceps tendon rupture.

With permission from Fernandez et al.: Maniobras exploratorias del hombro doloros martes, Fig. 4, p. 7. Seminarios de la Fundación Española de Reumatologia, July 13, 2010, Elsevier.

Etiology

A combination of traction, friction, shear, and compression of the tendon may lead to inflammation of the synovial lining covering the tendon.
In overhead athletes, biceps tendinopathy is more frequently isolated.
In the older adult population, tendinopathy is frequently associated with impingement and rotator cuff pathology.

Diagnosis

Differential Diagnosis

Rotator cuff tear: frequently associated, both pathologies may exist
Calcific tendonitis of the rotator cuff: acute, intractable pain is more frequently over the lateral shoulder, and calcified inclusions of the cuff tendons may be visible on x-ray
Glenohumeral osteoarthritis: may be diagnosed by degenerative changes on x-ray
Septic arthritis: often acute and associated with effusion, systemic signs of sepsis
Cervical radiculopathy: typically presents with weakness and/or sensory changes; radicular pain may radiate to the shoulder
SLAP or labral tears
Subacromial bursitis/impingement syndrome
Acromioclavicular joint arthritis

Workup

Diagnosis of biceps tendinopathy may be suspected from history and physical examination

Imaging Studies

MRI is frequently used to assist in the diagnosis and may demonstrate thickening and increased signal within the tendon. MRI should be obtained with acute trauma to rule out pathologies (e.g., acute rotator cuff tears) that should be addressed immediately for improved outcomes (Fig. E3).

FIG.E3

Distal biceps partial tear.

A, Sagittal fat suppressed T2-weighted and B, axial proton-density MR images demonstrate marked thickening of the discontinuity of the distal biceps tendon short-head fibers associated with increased intrasubstance signal consistent with severe tendinosis (white arrows). A distended bicipitoradial bursa is noted (black arrows). R, Radial tuberosity.

From Pope TL, et al.: Musculoskeletal imaging, ed 2, Philadelphia, 2014, Saunders.
Ultrasound may reveal the presence of an effusion or absence of the biceps tendon in the intertubercular groove (Fig. E4).

FIG.E4

Ultrasound image of bicipital tendonitis.

Transverse image shows large effusion in the long head of biceps tendon sheath.

From Hochberg MC, et al.: Rheumatology, ed 5, St Louis, 2011, Mosby.
Subluxation of the tendon may also be seen on MRI or ultrasound.
Suspicion of tendinopathy can be confirmed with arthroscopy.

Treatment

It is often necessary to establish whether the tendonitis is primary or secondary to address certain aspects of the treatment. Initial conservative treatment is usually very successful.

Nonsurgical Therapy

Nonsurgical treatment is typically appropriate in cases not involving acute trauma or other concomitant pathologies requiring immediate intervention. Rest and activity modification, NSAIDs, and physical therapy benefit many patients.

Patients who experience insufficient improvement after a 6- to 8-week period of conservative treatment may be considered for corticosteroid injection into either the glenohumeral joint or the tendon sheath itself. The tendon should never be directly injected, and ultrasound is recommended as an adjunct to improve accuracy of injections.

Surgical Treatments

Surgical management of the biceps tendon may include tenodesis (cutting the tendon and reattaching it at a more distal location along its course) or tenotomy (cutting the tendon without reattaching it distally).

Acute General Rx

Nonsteroidal antiinflammatory drugs (NSAIDs) are good adjuncts to treatment that expedite the recovery process by decreasing edema, inflammation, and pain.

Referral

Consider referral to a physical therapist early in treatment. Patients who do not improve with conservative management over 2-3 months or with acute concomitant pathologies (e.g., acute rotator cuff tear) should be considered for consult to an orthopedic surgeon.

Pearls & Considerations

Comments

Improved outcomes are noted from surgical fixation of acute tears of the rotator cuff within 6 weeks, so prompt workup and referral for these patients is imperative.

Ferri – Biceps Tendonitis