Biceps Tendinopathy

Original Editor - Cole Racich and Nick Tainter as part of the Temple University EBP Project

Top Contributors - Nick Tainter, Cole Racich, Abbey Wright, Lucinda hampton, Admin, Kim Jackson, Laura Ritchie, Rachael Lowe, George Prudden, Fasuba Ayobami, Evan Thomas, Wanda van Niekerk, Scott A Burns, David Herteleer and Jacob Bischoff  

Clinically Relevant Anatomy

The m.biceps brachii is innervated by the n. musculocutaneus (C5, C6 and C7). It exerts a flexion and supination from flexion in the elbow and in the shoulder it exerts an anteflexion. It also has a very important role in the stabilization of the humerus in the cavitas glenoidalis. The biceps has two proximal attachments:^{[4] level of evidence 2A}

• Caput longum: originates from the supraglenoid tubercle of the scapula and crosses over the head of the humerus within the gleno-humeral joint cavity, which is the intra-articular portion. The tendon then descends down the humerus via through 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).^{[4][3]level of evidence 2A}
• 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 tendinitis.

The distal attachment of the biceps is the radial tuberosity and fascia of the forearm by way of the biceps aponeurosis.^[1]

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.^[2] The long head of the biceps tendon also acts as a stabilizer for the anterosuperior 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.^[3] 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. ^{[4] level of evidence 2A}

Mechanism of Injury / Pathological Process

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. Complete rupture of the tendon can occasionally occur from a state of chronic inflammation or from a traumatic event (such as forceful elbow movements often associated with weightlifting). Anatomical morphology responsible for a rigid or narrow intertubercular sulcus may also inflame the biceps tendon; however, this correlation has been disputed in the literature.

Biceps tendinitis has been shown to be associated with rotator cuff tears, particularly those that involve the subscapularis tendon. Additionally, in chronic rotator cuff tears (> 3 months) there most likely will be some degree of macroscopic biceps abnormality. The presence of rotator cuff tears also correlates closely with the incidence of biceps tendon dislocations and medial subluxations.

The relationship between intertubercular sulcus integrity and biceps tendinitis 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 tendinitis or a rotator cuff pathology.

Overall, biceps tendinitis likely will present with concomitant shoulder pathologies, such as sub-acromial 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.

Clinical Presentation

Patients are likely to present with a chief complaint of anteromedial shoulder pain (usually over the bicipital groove region, but may extend over the muscle belly) often associated with a history of chronic overuse from repeated overhead activities. Pain may be aggravated by overhead reaching and lifting activities. Pain with palpation over the bicipital groove is another common physical exam finding for patients with biceps tendinitis. 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 tendinitis, as this motion involves contraction of the short head of the biceps brachii and the brachioradialis muscles. 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.

A thorough history for a patient presenting with possible biceps tendinitis should encompass questions concerning the history of any possible trauma, symptom onset and duration, easing and aggravating factors, and the presence of any instability, weakness, crepitus, numbness, and tingling.

Diagnostic Procedures

As with other shoulder pathologies it is important to include the following in your physical examination:
• Screening of the cervical spine
• Active Range of Motion (AROM) and Passive Range of Motion (PROM)
• Observation and palpation of key structures/regions
• Resistive testing
• Functional testing
• Findings of special tests

No validated cluster of diagnostic tests is currently available for ruling in or out biceps tendinitis specifically. Therefore, these tests should be used to help guide the diagnosis. Due to the lack of specificity in differentiating between biceps tendon pathology, sub-acromial 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.
The patient’s pain can often be elicited through palpation of the long head of the biceps tendon along the intertubercular groove on the anterior portion of the shoulder. The Speed’s test and the Yergason’s test are the main tests for biceps tendinitis and can be helpful in confirming your diagnosis. Both tests can be used to rule in the presence of a biceps pathology (tendinitis or rupture), SLAP lesion, shoulder impingement or rotator cuff pathology. It is important to remember that although these tests theoretically test the presence of a biceps tendon pathology, this relationship has not yet been examined in the literature.

Table 2: Special Tests

Test	Sensitivity	Specificity
Speed's	32%	75%
Yergason's	43%	79%

Outcome Measures

Disabilities of the Arm, Shoulder, and Hand (DASH), Quick DASH

Other Outcome Measures reported in the literature: The Constant Score, American Shoulder and Elbow Surgeons Shoulder Score (ASES), University of California Los Angles (UCLA), Wolfgang’s Criteria, Shoulder Pain and Disability Index (SPADI) and Simple Shoulder Test (SST)

Management / Interventions

In most cases of biceps pathology, conservative treatment will be the most appropriate option. Initial treatment of biceps tendinitis follows a traditional approach of rest, ice, and the use of nonsteroidal anti-inflammatory drugs, along with modification of aggravating activities. Physical therapy intervention should include restoring a pain free range of motion, trunk and core stability, as well as ensuring proper scapulothoracic rhythm. Pain free range can be achieved with such activities as PROM, Active-Assisted Range of Motion (AAROM), and mobilization. Painful activities such as abduction and overhead activities should be avoided in the early stages of recovery as it can exacerbate symptoms. Once a pain free range of motion is achieve, a strengthening program should begin with emphasis on the scapular stabilizers, rotator cuff and biceps tendon. For more chronic presentations, corticosteroid injections along the tendon sheath may be indicated. 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.

Differential Diagnosis

Differential Diagnosis of Anterior Shoulder Pain:
• Acromioclavicular joint pathology
• Adhesive capsulitis
• Cervical spine pathology
• Glenohumeral arthritis
• Glenohumeral instability
• Humeral head osteonecrosis
• Sub-acromial Impingement syndrome
• Rotator cuff tears
• Superior labrum anterior-posterior lesions (SLAP)

Key Evidence

Differential Diagnosis & Management/Interventions:

Krupp JK, Kevern MA, Gaines MD, Kotara S, Singleton SB. Long head of the biceps tendon pain: differential diagnosis and treatment. J Orthop Sports Phys Ther. 2009;39:55-70.

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