Updated: 3/24/2017

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
  • 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)
  • Prognosis
    • patients can fully recover within 6-8 weeks with proper management
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
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.OR.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? Review Topic | Tested Concept

QID: 109206
FIGURES:
1

Supraspinatus rupture

2%

(1/43)

2

Infraspinatus rupture

5%

(2/43)

3

Biceps tendinopathy

2%

(1/43)

4

Biceps tendon rupture

84%

(36/43)

5

Biceps muscle tear

5%

(2/43)

M2 D

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