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Proximal Biceps Tendon Injuries
From WikiSM
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
- Commonly occurs with other pathologic processes in the shoulder
- Rotator Cuff Tendinitis including Subscapularis injuries
- Trauma (direct or indirect)
- Inflammatory conditions
- Glenohumeral Internal Rotation Deficit (GIRD)
- Superior Glenoid Labral Tears (the “peel-back” mechanism)
- External impingement/Subacromial impingement syndrome (EI/SIS)
- Glenohumeral arthritis
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
- Biceps Brachii
- Long head originates from supraglenoid tubercle and superior Glenoid Labrum
- Bicipital Groove of the Humerus
- Anatomic landmark between greater and lesser tuberosities
- Serves as a critical location of proximal biceps stability
- Tendo-ligamentous sling overlies the long head in the groove
- Formed by Subscapularis, Supraspinatus, Glenohumeral ligament, Coracohumeral Ligament
- Forms a pulley system for the long head
- Function
- Role as a passive, possibly dynamic, stabilizer of shoulder
Associated Injuries
Risk Factors
- Sports[4]
- Baseball
- Softball
- volleyball
- Gymnastics
- Swimming
Differential Diagnosis
- Fractures
- Proximal Humerus Fracture
- Humeral Shaft Fracture
- Clavicle Fracture
- Scapula Fracture
- First Rib Fracture (traumatic or atraumatic)
- Dislocations & Separations
- Arthropathies
- Muscle & Tendon Injuries
- Rotator Cuff
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatrics
- Coracoid Avulsion Fracture
- Humeral Head Epiphysiolysis (Little League Shoulder)
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
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
- Biceps Tendinitis
- First line treatment
- Relative rest
- Medications including NSAIDS, Acetaminophen
- Physical Therapy
- Corticosteroid Injection into the tendon sheath under ultrasound guidance
- Biceps Instability
- Physical Therapy in older individuals
- In younger individuals, consider operative intervention
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
- Internal
- External
- Sports Medicine Review Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/
References
- ↑ 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.
- ↑ 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.
- ↑ Favorito PJ, Harding WG, Heidt RS. Complete arthroscopic examination of the long head of the biceps tendon. Arthroscopy. 2001;17:430–432.
- ↑ 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.
- ↑ Cone RO, Danzig L, Resnick D, et al. The bicipital groove: radiographic, anatomic, and pathologic study. AJR Am J Roentgenol. 1983;41:781–788.
- ↑ 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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