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Proximal Biceps Tendon Injuries

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Other Names

  • Biceps tendinitis
  • Biceps tendonitis
  • Proximal Biceps Tendinitis
  • Biceps Tendinopathy
  • Proximal Biceps Tendon Tear

Background

  • This page refers to proximal injuries to the Biceps Brachii including tendinopathies, instability and tears

Epidemiology

  • Tendonitis
    • Primary tendonitis makes up about 5% of proximal biceps pathology
    • 90% of rotator cuff tears have concomitant proximal biceps tendonitis[1]
  • Instability
    • Up to 45% of patients undergoing arthroscopic rotator cuff repair have biceps tendon instability[2]

Pathophysiology

Tendonitis

  • See: Tendinopathies (Main)
  • General
    • Inflammation typically occurs at the biceptal groove of the Humerus
    • Progresses to a tendinosis as time progresses
  • Primary is uncommon, frequently secondary[3]
    • Etiology for primary is not well understood
    • Seen in younger overhead athletes during late cocking phase (maximum abduction, external rotation) with eccentric contraction
  • Secondary is far more common

Instability

  • Spectrum ranges from subluxation to dislocation
  • Stabilized by rotator interval over the groove, which function as a pulley system to maintain the tendon within the bicipital groove
  • Subluxation associated with injuries to the rotator cuff and more specifically the Subscapularis muscle
  • Dislocation occurs deep to the subscapularis muscle

Pathoanatomy

Associated Injuries


Risk Factors

  • Sports[4]
    • Baseball
    • Softball
    • volleyball
    • Gymnastics
    • Swimming

Differential Diagnosis


Clinical Features

  • History
    • Onset is frequently insidious in nature
    • Patients may endorse a history of trauma, although this is less common
    • Will complain of pain over the anterior shoulder usually around the bicipital groove
    • In patients with instability, they may endorse popping or snapping
    • Worse with overhead activity
  • Physical: Physical Exam Shoulder
    • Most reliable exam finding is point tenderness over the bicipital groove
  • Special Tests
    • Speeds Test: Arm flexed forward to 90°, supinated and patient flexes against resistance
    • Yergasons Test: Elbow flexed to 90°, forearm is pronated, attempt to supinate
    • Passive Biceps Subluxation Test: extremes in range of motion to reproduce sensation of instability
    • Uppercut Test: Patient performs an uppercut maneuver against resistance
    • Lift Off Test: Hand behind back, push off against examiner
    • Ludington Test: Place hands on top of head, flex biceps, look for 'Popeye' deformity

Evaluation

Arm MRI: Tear of Long Head of Biceps Tendon
Short axis view of biceps tendon sheath with peritendinous fluid. This can be pathologic. In this case, there is a needle in plane performing a corticosteroid injection

Radiographs

  • Start with Standard Radiographs Shoulder
  • Typically normal
  • May reveal acromial spurring or hooking
  • Consider
    • Bicipital groove view: allows for evaluation of groove[5]
    • Fisk view: allows for evaluation of bicipital groove

MRI

  • Gold standard for evaluation biceps and bicipital groove
  • Characteristic findings
    • Tendinosis, partial tears, edema
  • Arthrography can improve delineation of intra-articular component of tendon

Ultrasound

  • Can be used to diagnose rupture, subluxation, dislocation or peritendinous edema
  • Not reliable for intra-articular tears
  • Characteristic findings:
    • Tendon thickening
    • Tenosynovitis/hypertrophy of the synovial sheath
    • Fluid surrounding the tendon in the groove
  • Sensitivity 50-96%, specificity 98-100% (need citation)

Classification

  • Not applicable

Management

Nonoperative

Operative

  • Indications
    • Refractory to conservative management
    • Significant fraying, tearing, hypertrophy
    • Partial thickness tears (>25-50%)
    • Subluxation
  • Technique
    • Tenotomy
    • Tenodesis

Rehab and Return to Play

Rehabilitation

  • Postoperative care varies based on procedure[6]
  • Tenotomy
    • Weeks 1-2: Sling
    • Weeks 2-4: Active ROM, discontinue sling
    • Weeks 4-6: Strengthening
  • Tenodesis
    • Weeks 1-4: Sling, with passive range of motion, grip strengthening
    • Weeks 5-6: full active and passive ROM, active flexion, supination

Return to Play

  • Light work 3-4 weeks post op
  • Unrestricted activity 3-4 months

Complications

  • Cosmetic "popeye" deformity
  • Muscle pain, spasms

See Also


References


  1. Beall DP, Williamson EE, Ly JQ, Adkins MC, Emery RL, Jones TP, Rowland CM. Association of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR Am J Roentgenol. 2003 Mar;180(3):633-9.
  2. Lafosse L, Reiland Y, Baier GP, et al. Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations. Arthroscopy. 2007;23:73–80.
  3. Favorito PJ, Harding WG, Heidt RS. Complete arthroscopic examination of the long head of the biceps tendon. Arthroscopy. 2001;17:430–432.
  4. Borms D, Ackerman I, Smets P, Van den Berge G, Cools AM. Biceps Disorder Rehabilitation for the Athlete: A Continuum of Moderate- to High-Load Exercises. Am J Sports Med. 2017 Mar;45(3):642-650.
  5. Cone RO, Danzig L, Resnick D, et al. The bicipital groove: radiographic, anatomic, and pathologic study. AJR Am J Roentgenol. 1983;41:781–788.
  6. Varacallo, Matthew, and Scott D. Mair. "Proximal Biceps Tendinitis and Tendinopathy." StatPearls [Internet]. StatPearls Publishing, 2019.
Created by:
John Kiel on 17 June 2019 19:17:28
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Last edited:
1 October 2022 19:08:28
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