Biceps Tendonitis & Rupture

Overview Bicipital tendinitis is an inflammatory process of the biceps tendon specifically the long head . Anatomy The biceps brachii has two heads: short and long heads. The biceps tendon travels through the bicipital groove on the front of the shoulder ball(prone to friction related inflammation). The tendon is exposed on the anterior shoulder as it passes through the humeral bicipital groove and inserts onto the superior aspect of the labrum of the glenohumeral joint. The biceps long head passes over the head of the humerus (ball joint) and attaches to the top of the shoulder socket. The long head of the biceps acts as a shoulder joint stabiliser through depression of the humeral head especially during abduction and external rotation. Bicipital tendinitis 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.[6]

Causes Rarely seen in isolation Occurs due to: Overuse Tendon impingement Shoulder joint instability Trauma Associated other shoulder pathologies: Rotator cuff impingement syndrome Rotator cuff tears Labral tears SLAP lesions

Signs and Symptoms Pain in the anterior shoulder over the bicipital groove, occasionally radiating down to the elbow.  Pain with heavy lifting or overhead activities, especially with combined abduction and external rotation e.g cocking to throw. Pain aggravated by shoulder flexion, forearm supination, and/or elbow flexion. Muscle weakness and clicking or snapping with shoulder movements. The symptoms are alleviated by rest and ice. Chronic tendonitis leading to biceps degeneration occasionally results in shoulder instability and subluxation resulting in a palpable snap in a painful arc of motion that is seen in throwing athletes. Superior labral tears (superior labrum anterior and posterior [SLAP] lesions) may have similar findings, but these injuries are more prone to locking or catching symptoms.[12]

Physical Evaluation Local tenderness over the bicipital groove which may be localized best with the arm in 10 º of external rotation. Flexion of the elbow against resistance aggravates the patient's pain. Passive abduction of the arm in an arc maneuver may elicit pain that is typical of impingement syndrome (negative in isolated tendonitis). Speed test: anterior shoulder pain with flexion of the shoulder against resistance, while the elbow is extended and the forearm is supinated. Yergason test: pain and tenderness over the bicipital groove with forearm supination against resistance, with the elbow flexed and the shoulder in adduction. Popping of subluxation of the biceps tendon may be demonstrated with this maneuver.

Management: Acute Phase Restrict over-the-shoulder movements, reaching, and lifting. Apply ice packs to the affected area for 10-15 minutes, 2-3 times per day for the first 48 hours. NSAIDs are used for 3-4 weeks to treat inflammation and pain Avoid prolonged immobilization- result in a stiff shoulder. Physical therapy plays a minor role in the treatment of acute bicipital tendinitis; however, some authors recommend daily weighted, pendulum stretch exercises for uncomplicated and mild cases of acute bicipital tendinitis. Use of transcutaneous electrical nerve stimulation (TENS) has been reported with some success. Phonophoresis and iontophoresis are examples of methods that are used to deliver steroids into inflamed tissue without an injection. Phonophoresis uses ultrasound, whereas iontophoresis uses electrical repulsion to transport medicines through the skin. In order to deliver an effective steroid concentration, the target area should be superficial, and serial application is necessary. The initial goals of the acute phase of treatment for bicipital tendinitis are to reduce inflammation and swelling.

Complications Direct injection into the long head of the biceps tendon itself for analgesics or steroid administration can result in direct trauma to — and may lead to atrophy and/or rupture of — the tendon. Other complications from injections include postinjection infection and inflammatory reaction. Consultations Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs. Other Treatment A local injection of an anesthetic and steroid can be given in the bicipital groove. A combination of 2-3 mL of anesthetic with 1 mL of methylprednisolone (Depo-Medrol; Pfizer Inc, New York, NY) is typically recommended 3-6 weeks after the acute injury. A repeat injection can be performed 4 weeks later if the symptoms have not decreased by 50%. Caution is indicated with additional injections or with patients older than 40 years because there is an increased risk of biceps tendon rupture from repetitive injections. Restrict lifting and overhead activities by the patient for 30 days after the injection.

Recovery Phase Rehabilitation Therapy Directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint while restoring the affected shoulder's ROM. The goal of the recovery phase is to achieve and maintain full and painless ROM. Weighted, pendulum stretch exercises are combined with isometric toning. These 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.

Recovery Phase Occupational Therapy Although a rehabilitation program should improve strength and flexibility, adding an interval program can help restore normal joint arthrokinematics. Interval tennis and baseball programs have been developed for highly competitive athletes as these individuals recover from bicipital tendinitis. The patient progresses in a series of steps and stages, with the goal of returning safely to competition without reinjury. The progression of therapy is dependent upon a gradual, painless increase in activity without excessive fatigue.

Recovery Phase Medical Issues/Complications Failure to recognize concomitant injuries with bicipital tendinitis 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. Other Treatment (Injection, manipulation, etc.)Weighted, pendulum swings should begin with moist heat application to the shoulder on the affected side, 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. Note: This exercise is not appropriate for patients who have shoulder separation or strain, upper back strain, or neck strain.

Surgical Intervention Indicated after a 6-month trial of conservative care is unsuccessful. Standard procedure is acromioplasty with anterior acromionectomy . Arthroscopic decompression is also used. The biceps tendon does not generally undergo tenodesis unless severe attritional wear or eminent rupture is found. No attempt is made to repair biceps tendon ruptures older than 6 weeks. 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[7, 25]: Greater than 25% partial-thickness biceps tendon tear Severe subluxation from the bicipital groove Disruption of the associated bony or ligamentous anatomy of the groove itself Biceps tendon atrophy greater than 25% Failure of surgical decompression

In this type of surgery, the lining around the tendon is opened and the inflammatory tissue is removed. The tendon is inspected for tears and, if found, they are repaired. Occasionally, a tendon will need to be lengthened or shortened, depending on the problem. NB:Bicipital tendinitis with labral tears or rotator cuff tears may not improve if all the conditions are not treated

Bicep Tendon Tears/Rupture Usually occurs with serious or constant overuse. A biceps tendon tear can happen at either the shoulder or the elbow and can be complete or partial. Partial traumatic ruptures may occur in combination with underlying tendinitis. A complete tear means the tendon has torn away from the bone. A tendon can also tear by moving or twisting the elbow or shoulder in an awkward way, or falling down with the arm outstretched. Tears at the elbow most often occur during the act of lifting a heavy object.

Signs and Symptoms Patients with rupture of the long head of the biceps tendon often report a sudden and painful sensation in the upper part of your arm or at the elbow along with feeling or hearing "pop" when the tendon tears. The retracted muscle belly bulges over the anterior upper arm, which is commonly described as the "Popeye" deformity. In patients without acute traumatic injuries, the biceps tendon rupture is usually preceded by a history of shoulder pain that quickly resolves after a painful audible snap occurs. Other signs of a torn biceps tendon can include: Sharp pain at the shoulder or elbow A bruise that appears on the upper arm A feeling of weakness in the shoulder or elbow Trouble rotating your arm from a "palm up" to a "palm down" position A change in the contour of the front of your arm While surgery may be needed to fix a torn tendon, in many cases people with a torn tendon can still function normally. Symptoms can be relieved using the same treatments that are used to treat tendonitis. Tears at the level of the elbow more often require operative repair.

Tears at the Shoulder Tears are more likely to occur in the long head. The short head tendon may allow you to continue using your biceps muscle in a complete tear of the long head. Tears of the short head are very rare. Treatment Conservative- patients might never regain all of their arm’s original strength. Surgical- to reattach a long head tendon. For those who continue to experience symptoms or who want to regain all of their arm strength and function. Re-tearing of the repaired tendon is rare. Flexibility and strengthening exercises to rehabilitate the shoulder will need to be done which can last for several months.

Tears at the Elbow Tears of the distal biceps tendon are unusual and most often result from an injury or lifting a heavy object. Tear is usually complete. Treatment Patients are still able to move their arms reasonably well, but with a decrease in arm strength thus persons usually opt for surgery.

Associated Sports shoulder instability. It is common in sports that involve throwing, swimmers, gymnasts and some contact sports. Occupations that involve overhead shoulder work or heavy lifting are at risk. baseball pitchers, swimmers, gymnasts, racquet sport enthusiasts (eg, tennis players), and rowing/kayak athletes. Trauma may occur because of direct injury to the biceps tendon when the arm is passed into excessive abduction and external rotation. This pattern of shoulder injury can also occur in the left shoulder of right-handed golfers. Many overuse injuries coexist with some degree of bicipital tendinitis and rotator cuff tendinitis.

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