Updated: 12/27/2021

Biceps Tendinopathy

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  • Snapshot
    • A 21-year-old man presents to the sports clinic for the evaluation of right-sided anterior shoulder pain that radiates to the biceps. The pain worsens when he pulls or lifts heavy objects and is also bothersome during the night. He plays football for his university where he trains approximately 5 times a week. On physical exam, there is tenderness of the right bicipital groove and a positive Speed's and Yergason's test.
  • Introduction
    • Clinical definition
      • describes biceps tendon pain and tenderness
  • Epidemiology
    • Incidence
      • exact frequency is unknown
    • Demographics
      • athletes
      • 18-35 years of age
    • Location
      • often the long head biceps tendon (LHBT)
      • can occur in the distal biceps tendon
    • Risk factors
      • patients who frequently pull, lift, reach, or throw are at risk
  • Etiology
    • Pathophysiology
      • pathoantomy
        • there are a number of possible causes
          • shoulder pathology (e.g., impingement or instability) can contribute to proximal biceps tendinopathy
            • changes in shoulder mechanics that stress the proximal LHBT results in
              • pathologic progression of the tendon (tendinitis → chronic tenosynovitis → degenerative tendinosis)
          • LHBT can become injuried via eccentric contraction of the biceps muscle (e.g., the decent phase of a pullup or shoveling heavy snow)
    • Associated conditions
      • shoulder pathology (e.g., issues with the rotator cuff and scapular stabilizers)
  • Presentation
    • Symptoms
      • anterior shoulder pain with distal radiation over the biceps muscle (classic)
        • pain worsens with lifting, pulling, or performing repetitive overhead activities
    • Physical exam
      • bicipital groove tenderness upon palpation of the LHBT
        • point tenderness of the biceps tendon has been regarded as pathognomonic for injury of the biceps tendon
      • Speed's test
        • maneuver
          • arm is fully supinated and extended with the shoulder flexed
            • the patient is asked to elevate the arm against resistance by the examiner
        • positive result
          • elicited anterior shoulder pain is considered a positive Speed's test
      • Yergason's test
        • maneuver
          • arm is adducted to the patient's side, is pronated, and flexed 90° at the elbow
            • the patient attempts to supinate and externally rotate the arm against resistance by the examiner
        • positive result
          • elicited pain at the long biceps tendon
  • Imaging
    • Radiographs
      • indications
        • to evaluate for bony causes of impingement
        • to rule out other causes of shoulder pain
    • Ultrasound
      • indications
        • can be useful is assessing for bicep rupture, subluxation, and dislocation
    • MRI
      • indications
        • if there is no improvement of symptoms after treatment or if the diagnosis is unclear
        • can be considered when there is a need to also evaluate for shoulder pathology
        • surgical planning
  • Studies
    • Diagnostic criteria
      • this is a clinical diagnosis
  • Differential
    • Rotatory cuff pathology
    • Glenohumeral osteoarthritis
    • Adhesive capsulitis ("frozen shoulder")
    • Cervical disk disease
  • Treatment
    • Conservative
      • rest and activity modification
        • indication
          • considered initial treatment of biceps tendinopathy and usually with a trial of NSAIDs
      • physical therapy
        • indication
          • can be used in cases of long-standing biceps tendinopathy or symptoms refractory to initial conservative treatment
    • Medical
      • NSAIDs
        • indication
          • usually in combination with rest in the initial treatment of biceps tendinopathy
      • Ultrasound-guided glucocorticoid injections
        • indication
          • can be used in patients who are refractory to conservative management (e.g., physical therapy, activity modification, and NSAIDs)
  • Complications
    • Biceps tendon rupture
      • patients can present with a "popeye" sign
  • Prognosis
    • Patients can fully recover within 6-8 weeks with proper management
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(M2.OR.17.4798) A 69-year-old male presents to his primary care physician for pain in his arm. The patient states that his father recently died of a heart attack which motivated him to join his local gymnasium. After completing a set of weight lifting, he felt a "pop" in his right arm, followed by pain. Since the incident, he has been unable to carry items or lift his arm over his head without difficulty and pain. The patient has a past medical history of obesity, diabetes, hypertension, and constipation. His current medications include lisinopril, metformin, insulin, and fiber supplements. On physical exam, you note pain with flexion of the forearm and abduction of the arm with 1/5 strength. There is also weakness of abduction of the affected arm with 3/5 strength. Inspection of the upper extremity reveals the finding in Figure A. Which of the following is the most likely diagnosis?

QID: 109206
FIGURES:

Supraspinatus rupture

4%

(2/50)

Infraspinatus rupture

4%

(2/50)

Biceps tendinopathy

2%

(1/50)

Biceps tendon rupture

82%

(41/50)

Biceps muscle tear

4%

(2/50)

M 6 E

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