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Introduction
  • Well recognized as a pain generator in the shoulder
  • Often associated with other primary shoulder pathology
    • subacromial impingement
    • stenosis of bicipital groove
    • rotator cuff tears
      • especially subscapularis pathology
  • Pathoanatomy
    • more consistent with "tendinosis" than true inflammation
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
      • indicates rupture
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 may be associated with arm cramping and cosmetic deformity ("Popeye deformity")
        • tenodesis may be associated with "groove pain" q
        • no difference in strength between two techniques - both recover elbow and forearm strength post-op 
 

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