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