Bicipital Tendonitis

Background

Biceps tendonitis is an inflammatory process of the long head tendon and is a common cause of shoulder pain due to its position and function. The tendon is exposed on the anterior shoulder as it passes through the humeral bicipital groove and inserts on the superior aspect of the labrum of the glenohumeral joint. Disorders can result from impingement or as an isolated inflammatory injury. Other causes are secondary to compensation to rotator cuff disorders, labral tears, and intra-articular pathology.

Frequency

United States

Biceps tendonitis is frequently diagnosed in association with rotator cuff disease as a component of the impingement syndrome or secondary to intra-articular pathology, such as labral tears.

Functional Anatomy

As its name implies, the biceps has 2 proximal heads with a common distal insertion into the radius. The long head of the biceps merges with the short head of the biceps to form the body of the biceps brachii muscle. This muscle is a powerful supinator and flexor of the forearm.

The long head tendon lies in the bicipital groove of the humerus between the greater and lesser tuberosities and angles 90° inward at the upper end of the groove, crossing the humeral head to insert at the upper edge of the glenoid labrum and supraglenoid tubercle. The long head biceps tendon helps stabilize the humeral head, especially during abduction and external rotation.

Sport Specific Biomechanics

Overhead athletes, most commonly baseball pitchers, tennis players, and swimmers, are prone to biceps tendonitis. Trauma may occur because of direct injury to the tendon as the arm is passed into excessive abduction and external rotation.

The athletic shoulder differs qualitatively from the biomechanics of daily life because of higher energies and repetitive motions involved in athletics. Sports requiring repetitive overhead motion may cause tendon breakdown with inadequate reparative time. Biceps tendonitis frequently occurs from overuse syndromes of the shoulder, which are fairly common in swimmers, gymnasts, racquet sport enthusiasts, and rowing/kayak athletes. This pattern of shoulder injury also can occur in the left shoulder of right-handed golfers. Many overuse injuries coexist with some degree of biceps tendonitis and rotator cuff tendonitis.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

The initial goals of the acute phase of treatment are to reduce inflammation and swelling. Patients should restrict over-the-shoulder movements, reaching, and lifting. Apply ice for 10-15 minutes, 2-3 times per day for the first 48 hours. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are used for 3-4 weeks to treat inflammation and pain. The degree of immobilization depends upon the degree of injury and discomfort. Most authors agree that prolonged immobilization tends to result in a stiff shoulder.

Physical therapy plays a minor role in the treatment of acute bicipital tendonitis; however, some authors recommend daily weighted pendulum stretch exercises for uncomplicated and mild cases of acute biceps tendonitis. Use of transcutaneous electrical nerve stimulation (TENS) has been reported with some success.

Phonophoresis and iontophoresis are examples of methods used to deliver steroids into inflamed tissue without injection. Phonophoresis uses ultrasound, while iontophoresis uses electrical repulsion to transport medicines through the skin. In order to deliver effective steroid concentration the target area should be superficial and serial application is necessary.

Medical Issues/Complications

Analgesic and steroid injections into the bicipital groove are not performed without risks. Use care to avoid direct injection into the long head biceps tendon itself because this can result in direct trauma and may lead to atrophy and/or rupture. Other complications from injections include postinjection infection and inflammatory reaction.

Radiographic imaging should be considered if no improvement occurs after treatment in order to exclude a possible missed diagnoses.

Consultations

Consider orthopedic consultation if symptoms persist longer than 2 months or if tendon rupture occurs.

Other Treatment

A local injection can be given in the bicipital groove. A combination of 2-3 mL of anesthetic with 1 mL of methylprednisolone (Depo-Medrol) typically is recommended 3-6 weeks after acute injury. A repeat injection can be performed 4 weeks later if symptoms have not decreased by 50%. Caution is indicated with additional injections or with patients older than 40 years because they are at an increased risk of tendon rupture from repetitive injections. Restrict lifting and overhead activities for 30 days after the injection.

Recovery Phase

Rehabilitation Program

Physical Therapy

The goal of the recovery phase is to achieve and maintain full and painless ROM. Weighted pendulum stretch exercises are combined with isometric toning. Exercises are recommended 3 times per week throughout the recovery phase. Passive stretching with ROM exercises removes residual shoulder stiffness. The uninvolved shoulder can be used as a standard comparison to achieve symmetric ROM.

Occupational Therapy

Interval tennis and baseball programs have been developed for highly competitive athletes. The patient progresses in a series of steps and stages, with the goal of returning safely to competition without reinjury. Progression is dependent upon gradual, painless increase in activity without excessive fatigue. While a rehabilitation program should improve strength and flexibility, adding an interval program can help restore normal joint arthrokinematics.

Medical Issues/Complications

Failure to recognize concomitant injuries could result in delayed healing and damage from inappropriate treatment. Physical therapy for shoulder injuries or a misdiagnosed injury may aggravate other conditions in the elbow and neck.

Consultations

Consider orthopedic consultation if symptoms persist longer than 2 months or if tendon rupture occurs.

Other Treatment (Injection, manipulation, etc.)

Weighted pendulum swings should begin with moist heat application to the shoulder, followed by therapy with 5- to 10-lb weights, which are held lightly in the hand. The shoulder muscle should be relaxed and the arm kept vertical and close to the body. The arm is allowed to swing back and forth, no greater than 1 inch in any direction. This exercise is not appropriate for patients with shoulder separation or strain, upper back strain, or neck strains.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase concentrates on developing increased strength and endurance. This phase can begin as soon as discomfort is effectively controlled and should continue for at least 3 weeks after pain has resolved completely. When performing strengthening exercises, it is safer to start out with low tension, followed by a gradual increase in force, because flare-ups can occur.

Isotonic and isokinetic stretching continues as the patient is allowed limited participation in sports activity. Monitor the patient and adjust activity as progress allows. Conditioning and proper throwing techniques are important for certain athletes because improper mechanics may result in tissue fatigue and damage.

Surgical Intervention

Surgical intervention is not recommended if the patient is making slow and gradual improvement. Surgical treatment is only indicated after a 6-month trial of conservative care is unsuccessful. Although good results have been reported using arthroscopic decompression, acromioplasty with anterior acromionectomy is the standard surgical treatment. The biceps tendon generally is not tenodesed unless severe attritional wear or eminent rupture is found. No attempt is made to repair ruptures greater than 6 weeks old.

Tenodesis is not recommended when it is believed that the tendinitis is reversible. Specific indications for tenodesis of the biceps long head include the following:

• Greater than 25% partial thickness tendon tear

• Severe subluxation from the bicipital groove

• Disruption of the associated bony or ligamentous anatomy of the groove itself

• Tendon atrophy greater than 25%

• Failure of surgical decompression

Growing evidence has shown a shift from routine tenodesis to a more individual approach, taking into consideration physiologic age, activity level, expectations, and specific combinations of shoulder pathology. While new repair techniques are under development, preservation of the biceps-labral complex is preferred over routine surgery.

Consultations

Consider orthopedic consultation if symptoms persist longer than 2 months or if tendon rupture occurs.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Anti-inflammatory and nonnarcotic medications that have analgesic and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions. Treatment of pain tends to be patient specific.

Drug Name	Ibuprofen (Ibuprin, Advil, Motrin)
Description	DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose	400-800 mg PO tid/qid
Pediatric Dose	<12 years: Not indicated >12 years: 20-40 mg/kg/d PO divided tid/qid
Contraindications	Documented hypersensitivity to ibuprofen, other NSAIDs, or aspirin; avoid in peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding
Interactions	Concomitant use with anticoagulants may potentiate anticoagulant effects; effects of oral diabetic hypoglycemic agents may be potentiated with combination use with ibuprofen, leading to hypoglycemia; may decrease clearance and absorption of methotrexate, lithium, diuretics, and antihypotensives
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Considered to be a class D drug in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Category: Local anesthetics

Block the generation of conduction impulses in the nerve, thereby preventing the transmission of pain.

Drug Name	Bupivacaine (Sensorcaine, Marcaine)
Description	An amide-type local anesthetic that shares similar properties with other drugs in this classification, including lidocaine (Xylocaine). Has the advantage of a longer duration of anesthesia. Administer smallest dose and concentration required to produce desired results. Dose varies with anesthetic procedure, area to be anesthetized, vascularity of the tissues, and individual tolerance.
Adult Dose	Local anesthesia: 5-10 mL (0.25% sol) 12.5-25 mg; not to exceed 2.5 g/kg
Pediatric Dose	<12 years: Not recommended >12 years: Administer as adults
Contraindications	Documented hypersensitivity
Interactions	May enhance effects of CNS depressants; coadministration may increase toxicity of MAOIs, TCAs, beta-blockers, vasopressors, and phenothiazines; have antiarrhythmic effects, which may cause additive toxicity interactions with phenytoin, procainamide, propanolol, and quinidine
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Systemic absorption produces effects on the cardiovascular and CNS; rate of absorption dependent upon the dose, rate of administration, and vascularity of the injection site; aspirate for blood prior to injection to avoid accidental intravenous administration; adverse reactions include restlessness, anxiety, dizziness, blurred vision, tremors, confusion, seizure, hypotension, palpitations, and syncope; consider reduced dose in patients with lowered hepatic clearance from disease or age

Drug Category: Glucocorticoids

Stimulate synthesis of enzymes that decrease inflammatory response and suppress the immune system.

Drug Name	Methylprednisolone acetate (Depo-Medrol)
Description	Methylprednisolone is a potent intermediate acting glucocorticoid, which has no mineralocorticoid activity. A useful anti-inflammatory and immunosuppressant agent.
Adult Dose	4-80 mg/d intra-articular, intrasynovial, intrabursal, intralesional, or soft tissue injection
Pediatric Dose	140-835 mcg/kg/d intra-articular, intrasynovial, intrabursal, intralesional, or soft tissue injection
Contraindications	Documented hypersensitivity to ingredients of adrenocorticoid preparations; systemic fungal infections
Interactions	Glucocorticoids may decrease effects of PO anticoagulants, isoniazid, insulin, PO hypoglycemic agents, and salicylates
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in hypertension, diabetes mellitus, tuberculosis, psychiatric disorders, glaucoma, and gastric ulcers; glucocorticoids suppress the immune system, which may result in complications in patients receiving live vaccines and in patients with concomitant infectious disease