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 With persistent inflammation, the intra-articular portion of the biceps tendon can become hypertrophied, leading to incarceration within the joint during movement, especially elevation 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 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