Bicep Anatomy
- Short head connects medial bicep muscle to coracoid process of the scapula (not suspectable to tendinopathy)
- Long head - connects to supraglenoid tubercle of the scapula and superior glenoid labrum - blood supply = anterior humeral circumflex artery.
- Inserts onto radial tuberosity
- Innervated by the Musculocutaneous nerve (C5-C6)
Bicipital Tendinitis
- Avascular parts of the long head of bicep tendon = deep undersurface of the tendon in the groove and proximal near insertion at the superior glenoid |
- Avascularity makes the long head of bicep tendon prone to injury at the bicipital groove in the proximal humerus |
- Can be acute inflammatory tendinitis to degenerative tendinopathy |
- Can be Primary (microtrauma, insidious)/Secondary (Primary more common) |
- Secondary:
- Rotator cuff tendinitis/tendinopathy (especially subscapularis)
- Subscapularis injuries
- LHB tendon instability/dislocation
- Direct/indirect trauma
- Inflammatory conditions
- Internal impingement of the shoulder (GIRD, superior labral lesions)
-External impingement/subacromial impingement
- GH OA |
Pathology
- Early tenosynovitis and inflammation when repeitive traction, friction and shoulder rotation occurs |
- Swelling occurs in the tendon due to inflammation tendon becomes mechanically irritated in the confined space |
- Tendon exposed to pathologic shear forces due to increased pressure and traction |
- Then the LHB sheath thickens as fibrosis and vascular compromise occurs |
- LHB starts to degenerate - scarring, fibrosis and adhesions, anchoring the tendon onto the groove, shear forces and traction increases |
- Tendon can rupture due to this anchoring |
Demographics
- Common in young adults (18-35) |
- Repetitive overhead activity (abduction and external rotation- peel back phenomenon, bicep muscle eccentrically contracts to decelerate elbow extension) |
- Throwers, swimming, gymnastics, martial arts, racquet sports, contact sports |
- Smokers |
- Biomechanical risks: Repetitve overhead activity, repetitive shoulder activity, improper lifting, shoulder girdle muscle imbalances, poor posture, inflexability, scapulothoracic or eccentric overload, trauma, osseous anatomical abnormalities (narrowing of bicepital groove - f#, OA and congenital disorders) |
Classification
Grade 0:
- Tenocytes normal
- Myxoid degenerative material not present
- Collagen remains arranged in tight, cohesive bundles
- Blood vessels arranged inconspiciously between collagen bundles |
Grade I:
- Tenocytes rounded
- Myxoid degenerative material present (small amounts)
- Collagen reminds arranged in discrete bundles with slight separation
- Capillary clustering (<1 cluster/ten high power fields) |
Grade II:
- Tenocytes rounded and enlarged
- Myxoid degenerative material evident (moderate-large amounts)
- Collagen bundles lose discrete organisation - separation between individual fibres and bundles increase
- Capillary clustering increased (1-2 clusters/ten high-power fields) |
Grade III:
- Tenocytes rounded and enlarged with abundant cytoplasm and lacuna
- Myoxid degenerative material abundant
- Collagen disorganised - loss of microarchitecture
- Capillary clustering increased (>2 clusters/ten high-power fields) |
Other changes: Tenosynovium: Synovial hypertrophy, hyperplasia and proliferation of the bicipital sheath/synovium |
Presentation
- Deep Throbbing ache over anterior shoulder or bicipital groove |
- May radiate to deltoid insertion/toward elbow/hand) |
- Provoked by overhead activity, flexion of elbow and shoulder, forearm supination |
- Can occur at night - sleeping on affected shoulder |
- Relief from heat, ice, stretching and massage |
- Rule out tendon rupture (painful audible pop then relief, popeye muscle on observation)
Risks: Chronic tendinopathy
Concurrent rotator cuff tear
Contralateral bicep tendon rupture
Age >40
Poor conditioning
RA or other rheumatologic pathology |
- Limited ROM - Active/resisted movements may provoke pain (forearm supination, elbow flexion, shoulder flexion) Consider labral injury if popping, catching or locking during AROM occurs |
- Tenderness in rotator interval and bicipital groove |
- +ve Yergasons, Speeds (most specific), Bear hug (most sensitive), Belly press(most specific), Upper cut (most sensitive), Backward Traction, Lippman test |
- Assess for dysfunction in Cx and Tx spine, Scapula dyskinesis, Upper crossed, AC joint, labral tear |
- Consider posterior capsule tightness |
- Consider Cx/Shoulder exam |
- Patient's occupational hx/current job/ hx of injury/trauma to the shoulder/neck, hand dominance, surgical hx |
- AROM, PROM Cx, AROM, PROM, RROM Shoulder |
- Strength of rotator cuff (strength tests and IR lag sign) |
- Check for Impingement signs (may be +ve due to swelling of the tendon) |
DDx
- Adhesive Capsulitis |
- Biceps tendon rupture |
- Cx radiculopathy |
- Brachial neuritis |
- AC joint pathology |
- GH Arthritis/ instability |
- Osteonecrosis of humeral head |
- Subacromial impingement syndrome |
- f# |
- Neoplasm |
- Rheumatologic disease |
- SLAP |
- GIRD |
- Calcific tendonitis |
- RC tears |
- AVN |
- Supracapular neuropathy |
- TOS |
- QSS |
- Rupture of pecs, deltoid, lats) |
- Scapulothoracic dyskinesia |
Imaging
- Tendon thickening, hypertrophy of synovial sheath and fluid surrounding tendon
- Only if need to rule out osseous impingement/bony pathology (A-P, Y view)
- US- Gold standard
- MRI - if rupture/labral tears
Management
- Rest, ice, activity modification, functional retraining (limit motion that requires repetitive overhead activity, elbow flexion, forearm supination) |
- 1st Phase: Pain relief and restoration of normal ROM, scapula stabilisation exercises (lower traps and serratus anterior), resisted internal and exernal rotation, low rows and cencentric bicep strengthening |
- STW: Transverse friction massage over biceps tendon |
- Myofascial release and stretching exercises of biceps, cx, shoulder and periscapular musculature |
- Pendulum circumduction, wall walking, cane/wand stretching in flexion and abduction, sleeper stretchers |
- 2nd Phase: Strengthen from isometric to concentric then eccentric |
- Advanced strengthening - Bear hug, reverse fly and resisted internal/exernal rotation at 90 degrees of abduction |
- SMT for Cx and Tx, scapula dyskinesis (strenghten periscapula, mobilisation of scapula) |
- NSAIDs |
- Surgical referral is considered if no better with conservative care greater than 3 months, intra operative findings of inflammed tendon (lipstick lesion, significant fraying, tearing, hypertrophy, partial thickeness tears, medial LHB subluxation and LHB subluxation with subcapularis tear/bicipital groove soft tissue compromise |
- Corticosteroids if symptoms persistent and no better with conservative care |
Surgical complications
Tenotomy: Popeye deformity
Muscle spasm/cramping
Biceps pain |
Biceps Tenodesis: Groove pain
Popeye deformity
Muscle spasm/cramping
Biceps pain
Humeral shaft fracture (spiral when humerus is stressed torsionally) |
Post surgical Rehab
Tenotomy: Sling for 1-2 weeks
- AROM 2-4 weeks post op, sling discontinued
- Strengthening 4-6 weeks
- Light work 3-4 weeks post op
- Full return 1-3 months post op
- Unrestricted activities 3-4 months post op |
Tenodesis: Sling 3-4 weeks
- PROM and grip strengthening
- Avoid active elbow flexion and forearm supination for 6 weeks
- Full AROM and PROM should be achieved by six weeks
- Light work 3-4 weeks post op
- Full duty 2-4 months post op
- Unrestricted activities 3-4 months post op |
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