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Home , Bicipital groove, Tenosynovitis

Diagnosis and Treatment of Tendinitis and Tendinosis CATHERINE A. CHURGAY, MD, St. Luke’s Hospital/The University of Toledo Family Medicine Residency Program, Toledo, Ohio

Biceps tendinitis is of the around the long head of the biceps muscle. Biceps tendinosis is caused by degeneration of the tendon from athletics requiring overhead motion or from the normal aging process. Inflam- mation of the biceps tendon in the bicipital groove, which is known as primary biceps tendinitis, occurs in 5 percent of patients with biceps tendinitis. Biceps tendinitis and tendinosis are commonly accompanied by tears or SLAP (superior labrum anterior to posterior) lesions. Patients with biceps tendinitis or tendinosis usually complain of a deep, throbbing ache in the anterior . Repetitive overhead motion of the initiates or exacerbates the symptoms. The most common isolated clinical finding in biceps tendinitis is bicipital groove point tenderness with the arm in 10 degrees of internal rotation. Local anesthetic injections into the biceps tendon sheath may be therapeutic and diagnostic. Ultrasonography is preferred for visualizing the overall tendon, whereas magnetic resonance imaging or computed tomography arthrography is preferred for visualizing the intra-articular tendon and related pathology. Conservative management of biceps tendinitis consists of rest, ice, oral analgesics, physical therapy, or corticoste- roid injections into the biceps tendon sheath. Surgery should be considered if conservative measures fail after three months, or if there is severe damage to the biceps tendon. (Am Fam Physician. 2009;80(5):470-476. Copyright © 2009 American Academy of Family Physicians.)

iceps tendinitis is a disorder of the 35 years or nonathletes older than 65 years) tendon around the long head of the may have acute biceps tendinitis caused by biceps muscle. Inflammation of the sudden overuse, or biceps tendinosis caused biceps tendon within the intertu- by use over time.4 Primary impingement B bercular (bicipital) groove is called primary syndrome is considered the most common biceps tendinitis, which occurs in 5 percent cause of biceps tendinosis or tenosynovitis of patients with biceps tendinitis.1 The 95 per- (i.e., inflammation of the tendon sheath).4 cent of patients without primary biceps ten- Primary impingement is a mechanical dinitis usually have an accompanying rotator impingement under the coracoacromial arch cuff tear or a tear of the superior labrum caused by spur formation of the acro- anterior to posterior, known as a SLAP lesion. mion, an unfused acromial apophyses, or Pathology of the biceps tendon is most often thickening of the coracoacromial ligament. found in patients 18 to 35 years of age who are It may also be caused by osteoarthritic spurs involved in sports, including throwing and impinging on the bicipital groove.3 Primary contact sports, swimming, gymnastics, and impingement in athletes older than 35 years martial arts. These patients often have sec- leads to a higher incidence of rotator cuff ondary impingement of the biceps tendon, tears than in younger athletes. which may be caused by scapular instability, shoulder ligamentous instability, anterior Anatomy and Physiology capsule laxity, or posterior capsule tightness. The long head of the biceps tendon rises from Secondary impingement may also be caused the and the superior by labral tears or rotator cuff tears glenoid labrum. The proximal portion of that expose the biceps tendon to the cora- the long head of the biceps tendon is extra- coacromial arch2,3 (Figure 1). synovial but intra-articular.5 The tendon Biceps tendinitis may also refer to tendino- travels obliquely inside the , sis, which is a syndrome of overuse and degen- across the humeral head anteriorly, and exits eration. Older patients (i.e., athletes older than the joint within the bicipital groove of the

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Evidence Clinical recommendation rating References

Bicipital groove point tenderness is the most common isolated finding during physical examination of C 1 patients with biceps tendinitis. Ultrasonography is the best modality for evaluating isolated biceps extra-articularly. If C 3, 5, 14, 33-41 other pathology is suspected, magnetic resonance imaging should be performed. Biceps tenodesis may be performed in patients younger than 60 years, athletes, manual laborers, and C 14, 42, 43 patients who object to a muscle bulge above the elbow.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

humeral head beneath the transverse humeral ligament. (e.g., rheumatoid , lupus), infectious, or other The bicipital groove is defined by the greater tuberosity types of reactive or inflammatory conditions. (lateral) and the lesser tuberosity (medial). The biceps tendon is contained in the rotator interval, a triangular Diagnosis area between the subscapularis and supraspinatus ten- History and Physical Examination dons at the shoulder (Figure 1). The rotator interval is Patients with biceps tendinitis often complain of a deep, responsible for keeping the biceps tendon in its correct throbbing ache in the anterior shoulder. The pain is usu- location.6-8 Because the rotator interval is usually indis- ally localized to the bicipital groove and may radiate tinguishable from the rotator cuff and capsule, lesions of toward the insertion of the deltoid muscle, or down to the the biceps tendon are usually accompanied by lesions of in a radial distribution. This makes it difficult to the rotator cuff.9 distinguish from pain that is secondary to impingement SLAP lesions are often present in patients with biceps or tendinitis of the rotator cuff, or cervical disk disease.14 tendinitis and tendinosis. The anterosuperior labrum Pain from biceps tendinitis usually worsens at night, and superior labrum are more likely to tear than the infe- especially if the patient sleeps on the affected shoulder. rior portion of the labrum because they are not attached Repetitive overhead arm motion, pulling, or lifting may as tightly to the glenoid.9-13 also initiate or exacerbate the pain.9 The pain is most Additionally, certain conditions that affect the gleno- noticeable in the follow-through of a throwing motion.3 humeral joint may also involve the biceps tendon because Instability of the tendon may present as a palpable or it is intra-articular. These may include rheumatologic audible snap when range of motion of the arm is tested. Rupture of the biceps tendon is one of the most com- mon musculotendinous tears. If the biceps has ruptured, Acromioclavicular joint Coracoacromial ligament patients will describe an audible, painful popping, fol- lowed by relief of symptoms. The anterior shoulder may be bruised, with a bulge visible above the elbow as the Supraspinatus tendon muscle retracts distally from the rupture point. Risk fac- tors of biceps rupture include a history of rotator cuff Bicipital tear, recurrent tendinitis, contralateral biceps tendon groove rupture, rheumatoid arthritis, age older than 40 years, and poor conditioning.9 If a patient has a feeling of pop- ping, catching, or locking in the shoulder, a SLAP lesion may be present. This usually occurs after trauma, such as a direct blow to the shoulder, a fall on an outstretched 12,14-17 Glenoid tubercle arm, or repetitive overhead motion in athletes. (origin of biceps The most common finding of biceps tendon injury tendon—long head) is bicipital groove point tenderness.1 During physical ck Tendon of biceps—long head examination, the patient stands or sits with the arm at artso

ia h his or her side in 10 degrees of internal rotation. When c ar the arm is in this position, the humeral head with the bicipital groove faces forward. External rotation of the arm and humeral head places the tender bicipital groove

ILLUSTRATION m BY in a posterolateral position. This movement is one of the Figure 1. Anatomy of the long head of the biceps tendon. most specific findings of biceps tendon injury.1

September 1, 2009 ◆ Volume 80, Number 5 www.aafp.org/afp American Family Physician 471 Biceps Tendinitis ck ck artso artso ia h ia h c c ar ar ILLUSTRATION m BY ILLUSTRATION m BY Figure 2. Yergason test. Figure 4. Hawkins test. ck artso ia h c ar ILLUSTRATION m BY Figure 3. Neer test. ck artso ia h

Many provocative tests (i.e., Yergason, Neer, Hawkins, c and Speed tests) have been developed to isolate pathology ar of the biceps tendon12; however, because these tests cre- ate impingement underneath the coracoacromial arch,

it is difficult to rule out concomitant rotator cuff lesions. ILLUSTRATION m BY The Yergason test requires the patient to place the arm at Figure 5. Speed test. his or her side with the elbow flexed at 90 degrees, and supinate against resistance18 (Figure 2). The test is con- impingement is present, which can lead to biceps tendi- sidered positive if pain is referred to the bicipital groove. nitis or tendinosis. The Neer test involves internal rotation of the arm while Scapular dysfunction should be suspected if the in the forward flexed position16 (Figure 3). If the patient patient has evidence of medial or inferomedial border experiences pain, it is a positive sign of impingement prominence of the when viewed posteriorly with syndrome. During the Hawkins test, the patient flexes the patient at rest.2 Posterior capsule tightness is appar- the elbow to 90 degrees while the physician elevates the ent with decreased internal rotation of the shoulder.3 The patient’s shoulder to 90 degrees and places the in anterior slide test can identify SLAP lesions9 (Figure 6). a neutral position19 (Figure 4). With the arm supported, With the patient in a -on-hips position, the scapula the is rotated internally. The test is positive and are stabilized by one of the examiner’s hands if bicipital groove pain is present. For the Speed test, while the other hand is used to apply anterior-superior the patient tries to flex the shoulder against resistance force at the elbow of the affected side. A positive test is with the elbow extended and the forearm supinated9,20 a “click” or “pop” localized to the anterior shoulder and (Figure 5). A positive test is pain radiating to the bicipital felt underneath the examiner’s hand on the acromion, or groove. If any of these tests is positive, it indicates that the reproduction of painful symptoms.21

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Figure 7. Biceps tendon sheath injection. The blue lines Figure 6. Anterior slide test. outline the biceps tendon sheath and the red lines indi- cate the placement of the injection into the biceps ten- don sheath. Diagnostic and Therapeutic Injections Injections of a local anesthetic may further differentiate Table 119,26,28 and Figure 7 describe the specifics of the the origin of shoulder pain. An injection of 8 to 10 mL biceps tendon sheath injection, and Table 2 compares var- of 1% lidocaine (Xylocaine) into the subacromial space ious corticosteroid solutions and proper dosages. Ultra- under sterile conditions should relieve the pain of rotator sonographic guidance may increase the accuracy of the cuff tendinitis, but not that of biceps tendinitis.22 A local injection and has been shown to produce a fivefold anesthetic or corticosteroid solution may be injected into increase in analgesic effect.29,30 Ultrasonography may the biceps tendon sheath, but the injection must not enter also be used to aspirate and disperse calcific deposits the tendon because of the risk of rupture.5-8,10-12,14,15,23-27 within the of the rotator cuff.28,31

Table 1. Biceps Tendon Sheath Injection

1. Obtain oral or written informed consent. The potential risks 4. If a corticosteroid injection is required, use a hemostat between the of the injection include infection; bleeding; skin atrophy needle and skin to hold the needle in place while changing to the and depigmentation; allergic reaction to medication; or 1- or 3-mL syringe containing the corticosteroid solution. temporarily increased pain. 5. After the corticosteroid solution is injected, remove the syringe and 2. Assemble the necessary equipment. The injection requires a 21- reattach the 10-mL syringe with lidocaine and sodium bicarbonate. or 22-gauge 1.5-inch needle, 8 mL of 1% lidocaine (Xylocaine), Slowly withdraw the needle while injecting the remaining lidocaine 1 mL of 8.4% sodium bicarbonate to decrease the sting of and sodium bicarbonate. This will flush any remaining corticosteroid the injection, one 10-mL syringe, one 1- or 3-mL syringe, solution out of the needle, lessening the chance that any remaining corticosteroid solution (Table 2), alcohol wipes, povidone-iodine solution might cause skin atrophy or depigmentation. An alternative wipes or swabs, some 2- × 2-inch pieces of gauze, a plastic technique is to combine the lidocaine with sodium bicarbonate and bandage, gloves (sterile or nonsterile), and a marking pen. corticosteroid solution in the same syringe to avoid changing syringes. 3. Sterilize the injection area and use the thumb to palpate the 6. Apply the plastic bandage. Instruct the patient to keep it on for point that is most painful over the bicipital groove. Confirm eight to 10 hours and watch for signs of infection, which may this is the biceps tendon by externally rotating the arm and include erythema, increased pain, pus at the injection site, and a placing the elbow in 90 degrees of flexion. Insert the 10-mL low-grade fever of 100.4°F (38°C) or higher. syringe of 1% lidocaine plus sodium bicarbonate with the 7. Reexamine the patient after 15 to 20 minutes. Pain relief indicates a 21- or 22-gauge 1.5-inch needle subcutaneously parallel to diagnosis of biceps tendinitis. Confirm the diagnosis by performing the bicipital groove. Inject approximately 5 mL of lidocaine the Yergason test. It should be negative. A patient may also report plus sodium bicarbonate around the biceps tendon sheath in pain relief if there is instability or subluxation of the biceps tendon. If a fan-like distribution after aspirating and checking to avoid the shoulder is still painful, consider problems with the rotator cuff, blood vessels. Ensure that the injection is not into the tendon adhesive capsulitis, , or subacromial . itself because of the risk of rupture.

Information from references 19, 26, and 28.

September 1, 2009 ◆ Volume 80, Number 5 www.aafp.org/afp American Family Physician 473 Biceps Tendinitis Table 2. Corticosteroid Dosages for Biceps Tendinitis Injections

Preparation Common dosages strength for tendon sheath Radiologic Examination Corticosteroid (mg per mL) injection (mg) Radiologic evaluation to diagnose biceps ten- Triamcinolone acetonide (Kenalog) 10 5.0 to 10.0 dinitis or tendinosis should begin with radi- Methylprednisolone (Depo-Medrol) 20 5.0 to 10.0 ography of the shoulder to rule out primary Dexamethasone 4 0.8 to 2.0 causes of impingement (Table 35,10,12,14,32-41). Betamethasone acetate, 6 1.5 to 3.0 Negative results on radiography should be betamethasone sodium phosphate followed by ultrasonography of the shoulder, (Celestone Soluspan) which is the best method by which to extra- note: Listed in order of frequency of use. articularly visualize the biceps tendon. Sus- pected accompanying anatomic lesions may

Table 3. Advantages and Disadvantages of Radiologic Imaging Studies in the Evaluation of Biceps Tendinitis

Imaging study Advantages Disadvantages

Arthrography (used CT arthrography shows biceps tendon subluxations, ruptures, Invasive with MRI or CT to dislocations, and SLAP lesions14 Filling of the biceps tendon sheath is visualize the joint MRI arthrography is preferable for diagnosing biceps lesions unreliable40 capsule and glenoid 14 and SLAP lesions because the agreement between MRI and Sharp images of the tendon may be lost 41 labrum)39 arthroscopy for biceps lesions is only 37 percent and 60 percent Ionizing radiation for rotator cuff lesions

Bicipital groove view Shows the width and medial wall angle of the bicipital groove, Does not show possible intra-articular radiography 33 spurs in the groove, and supertubercular bone spur or ridge disorders of the labrum (soft tissue Inexpensive12 injuries)32

MRI Excellent evaluation of the superior labral complex and biceps Partial tears of the biceps tendon are tendon39 more difficult to detect than complete ruptures Expensive5 Poorly correlated with arthroscopy14

Radiography Rules out shoulder fracture and strains or dislocations of the Shows only bony origins of impingement (anteroposterior acromioclavicular joint and arthritis of the glenohumeral and syndrome and not soft tissue views of the shoulder acromioclavicular joint and acromioclavicular Inexpensive joint, lateral , Cystic changes in the lesser tuberosity are a sign of biceps outlet view, and tendinosis or upper subscapularis tear14 ALVIS view)10 In impingement syndrome, a subacromial spur is usually visible on the outlet and ALVIS views

Ultrasonography Relatively inexpensive Requires an experienced operator May be used for patients with metallic implants High frequency array transducer Dynamic Blind areas Widely available Difficult to scan patients who are No ionizing radiation obese14,33-39 Offers better spatial resolution than MRI and may be used for local anesthetic or corticosteroid injections into the biceps tendon sheath14,33-39 An overall sensitivity of 49 percent and a specificity of 97 percent

ALVIS = anterolateral view impingement syndrome; CT = computed tomography; MRI = magnetic resonance imaging; SLAP = superior labrum anterior to posterior. Information from references 5, 10, 12, 14, and 32 through 41.

474 American Family Physician www.aafp.org/afp Volume 80, Number 5 ◆ September 1, 2009 Biceps Tendinitis

be seen with magnetic resonance imaging (MRI).3,5,14,33-41 patients younger than 60 years, as well as active patients, Many surgeons prefer obtaining MRI arthrography or athletes, manual laborers, and patients who object to a computed tomography arthrography before surgery to muscle bulge above the elbow.14,42,43 visualize the intra-articular tendon and related pathol- ogy. If the patient demonstrates shoulder weakness and The Author pain with an intact rotator cuff and labrum, electromy- ography should be performed to rule out a neuropathy.3 CATHERINE A. CHURGAY, MD, FAAFP, is a clinical associate professor at St. Luke’s Hospital/The University of Toledo (Ohio) Family Medicine Resi- dency Program. Treatment Conservative Address correspondence to Catherine A. Churgay, MD, FAAFP, Depart- ment of Family Medicine, Dowling Hall, Suite 2240, The University of Biceps tendinitis or tendinosis may respond to analgesia Toledo College of Medicine, 3000 Arlington Ave., M.S. 1179, Toledo, with nonsteroidal anti-inflammatory drugs (NSAIDs), OH 43614. Reprints are not available from the author. acetaminophen (to avoid side effects from NSAIDs), Author disclosure: Nothing to disclose. ice, rest from overhead activity, or physical therapy.14 Rehabilitation of an athlete’s shoulder involves four REFERENCES phases: rest; stretching exercises of the scapula, rotator cuff, and posterior capsule; strengthening; and a pro- 1. Patton WC, McCluskey GM III. Biceps tendinitis and subluxation. Clin Sports Med. 2001;20(3):505-529. gressively difficult throwing program. The patient may 2. Kibler WB. Scapular involvement in impingement: signs and symptoms. begin exercises after the shoulder is pain-free. 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