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Proximal Biceps Tendon Injuries

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Other Names

  • Biceps tendinitis
  • Biceps tendonitis
  • Proximal Biceps Tendinitis
  • Biceps Tendinopathy

Background

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

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

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:
12 April 2022 17:11:37
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