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Updated: Jun 28 2024

Biceps Tendonitis

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  • summary
    • Biceps tendonitis is a well recognized source of anterior shoulder pain that may be associated with subscapularis tears and subacromial impingement.
    • Diagnosis can be suspected clinically with anterior shoulder pain made worse with provocative tests and confirmed with MRI studies to evaluate for concurrent pathology.
    • Treatment involves an initial trial of NSAIDs, activity modification and physical therapy. Arthorscopic versus open biceps tenodesis/tenotomy is indicated for recurrent symptoms.
  • Etiology
    • Pathoanatomy
      • more consistent with "tendinosis" than true inflammation
    • Often associated with other primary shoulder pathology
      • subacromial impingement
      • stenosis of bicipital groove
      • rotator cuff tears
        • especially subscapularis pathology
  • Anatomy
    • Glenohumeral anatomy
    • Bicep long head tendon
      • originates off supraglenoid tubercle and superior labrum
      • stabilized within bicipital groove by transverse humeral ligament
  • Presentation
    • Symptoms
      • pain
        • anterior shoulder pain
        • may have pain radiating down the in the region of the biceps
        • symptoms may be simillar in nature and location to rotator cuff or subacromial impingement pain
    • Physical exam
      • tenderness with palpation over biceps groove
        • worse with arm internally rotated 10 degrees
      • Speed test
        • pain elicited in bicipital groove when patient attempts to forward elevate shoulder against examiner resistance while elbow extended and forearm supinated.
        • may also be positive in patients with SLAP lesions.
      • Yergason's test
        • pain elicited in biceps groove when patient attempts to actively supinate against examiner resistance with elbow flexed to 90-degrees and forearm pronated
      • "popeye" deformity
  • Imaging
    • Ultrasound
      • can show thickened tendon within bicipital groove
    • MRI
      • can show thickening and tenosynovitis of proximal biceps tendon
        • increased T2 signal around biceps tendon
  • Treatment
    • Nonoperative
      • NSAIDS, PT strengthening, and steroid injections
        • indications
          • first line of treatment
        • technique
          • direct steroid injection in proximity, but not into tendon
    • Operative
      • arthroscopic tenodesis vs. tenotomy
        • indications
          • surgical release reserved for refractory cases for bicep pathology seen during arthroscopy
        • technique
          • repair vs. release/tenodesis
        • post-op rehab: tenodesis
          • avoid active forearm supination with the elbow at 90° of flexion
        • outcomes
          • tenotomy is associated with increased rate of cosmetic deformity ("Popeye deformity")
          • tenodesis may be associated with "groove pain"
            • suprapectoral versus subpectoral 
              • similar outcomes in residual pain, bicipital groove pain, Popeye deformity, range of motion, and patient-reported outcomes
          • no difference in strength, functional outcomes, or range of motion between tenotomy and tenodesis
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