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BICEPS TENDINOPATHY

What is the Biceps Tendon?

  • The biceps tendon in the shoulder is composed of two heads: the long head and the short head.

    • The long head of the biceps tendon (LHBT) originates from the supraglenoid tubercle of the scapula and the superior glenoid labrum within the shoulder joint. It travels through the shoulder joint, exits the joint capsule, and runs through the
      bicipital groove (also known as the intertubercular sulcus) of the humerus.

    • The short head of the biceps tendon originates from the coracoid process of the scapula [Nakata et al, 2011; Erickson et al, 1992; Katsuki et al, 2018].

    • The LHBT is stabilized by the biceps pulley, a capsuloligamentous complex that includes the superior glenohumeral ligament, the coracohumeral ligament, and the distal attachment of the subscapularis tendon [Nakata et al, 2011].

  • This complex helps maintain the position of the tendon within the bicipital groove and contributes to the stability of the shoulder joint. Understanding the precise anatomy and course of the LHBT is crucial for diagnosing and managing shoulder pathology, such as biceps tendinitis, SLAP lesions, and biceps tendon instability [Nakata et al, 2011; Erickson et al, 1992].

What is Biceps Tendinopathy?

  • Biceps tendinopathy refers to a spectrum of disorders affecting the long head of the biceps tendon (LHBT), characterized by pain and dysfunction.

  • Histologic studies, such as those by Streit et al. (2015), have shown that pain from the biceps brachii tendon is rarely due to inflammation. Instead, the tendon changes are consistent with a chronic degenerative process [Streit et al, 2015].

    • Histopathologic analyses of the LHBT in patients undergoing tenodesis have demonstrated advanced degenerative changes, including myxoid degeneration, collagen disorganization, and increased vascularization, with minimal evidence ofacute inflammation [Simon et al, 2022].

    • These findings are consistent with tendinosis, a condition marked by chronic degeneration rather than acute inflammatory changes.The term "tendinopathy" is preferred over "tendinitis" because it more accurately reflects the underlying pathology, which involves a disordered and degenerative healing process rather than inflammation [Kane et al, 2019].

    • This distinction is important for clinical management, as treatments targeting inflammation, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, may not address the root cause of the pain and dysfunction in tendinopathy.

  • In summary, biceps tendinopathy is primarily a chronic degenerative condition rather than an inflammatory one, as evidenced by histologic studies showing minimal inflammation and significant degenerative changes in the tendon [Simon et al, 2022].

How do you know if you have biceps tendinopathy?

  • To determine if you have biceps tendinopathy, a thorough clinical evaluation is essential. This includes a detailed patient history, physical examination, and appropriate imaging studies.
  • Clinical History and Physical Examination: Patients with biceps tendinopathy typically report a deep, throbbing ache in the front of the shoulder, often exacerbated by repetitive overhead activities or extending the shoulder backwards.
    • Symptoms of Biceps Tendinopathy often include:
      • Anterior Shoulder Pain: A deep, throbbing ache in the anterior shoulder, often exacerbated by repetitive overhead activities [Churgay, 2009; Chalmers & Verma, 2016].
      • Tenderness: Point tenderness over the bicipital groove, especially with the arm in slight internal rotation [Churgay, 2009].
      • Pain with Resisted Movements: Pain during resisted shoulder flexion or supination, often elicited during Speed's or Yergason's tests [Ben Kibler et al, 2009].
      • Weakness: Possible weakness in shoulder flexion and supination due to pain or tendon degeneration [Churgay, 2009].
      • Symptoms of SLAP Tears and Biceps Tendinopathy may overlap, and both conditions can coexist, making clinical diagnosis challenging. Imaging studies such as MRI or MR arthrography can aid in differentiating these conditions by visualizing the tendon and labral structures [Carr et al, 2015; Chang et al, 2008].
    • Physical examination findings may include tenderness over the bicipital groove, pain with resisted shoulder flexion, and positive provocative tests such as the Speed's and Yergason's tests [Carr et al, 2015; Churgay, 2009].
  • Imaging Studies: Imaging can aid in the diagnosis of biceps tendinopathy.
    • Ultrasonography is useful for visualizing the tendon and detecting structural abnormalities. It offers several advantages over other imaging modalities, including high sensitivity and specificity, real-time dynamic assessment, and cost-effectiveness.
      • A systematic review and meta-analysis by Courage et al. (2023) demonstrated that ultrasound is more reliable than clinical tests for both confirming and ruling out long head of the biceps tendon (LHBT) pathology. The study reported high sensitivity and specificity for detecting full-thickness tears (sensitivity: 0.88-0.95, specificity: 0.71-0.98) and moderate sensitivity and high specificity for partial-thickness tears (sensitivity: 0.27-0.71, specificity: 0.71-1.00) [Courage et al, 2023].
      • Bélanger et al. (2019) also highlighted the high specificity of high-resolution ultrasound (HRUS) for diagnosing LHBT pathology, with pooled positive and negative likelihood ratios of 38.00 and 0.24 for dislocation, and 35.50 and 0.30 for complete rupture, respectively [Bélanger et al, 2019]. This underscores the reliability ofultrasound in confirming suspected biceps tendinopathy.
      • Chen et al. (2011) compared physical examinations with musculoskeletal ultrasound and found that ultrasound had superior diagnostic accuracy for biceps tendinopathy. The study reported that ultrasound could reliably diagnose biceps pathology, with higher sensitivity and specificity compared to clinical tests [Chen et al, 2011].
    • Magnetic resonance imaging (MRI) can provide detailed images of the intra-articular portion of the tendon and associated pathologies, although it has limitations in sensitivity.
      • MRI can detect changes in tendon diameter, contour irregularities, and alterations in signal intensity. These findings correlate with the chronic degenerative changes observed histologically, such as collagen disorganization, tenocyte enlargement,and increased vascularization.
        • A study by Kim et al. demonstrated that standard non-enhancing 3-Tesla MRI has high diagnostic value for detecting long head of the biceps tendon (LHBT) pathology. The study found that using criteria of "at least 2 abnormal signs" (diameter change, contour irregularity, and alteration of signal intensity) achieved high diagnostic efficacy with a sensitivity of 77.9% and specificity of 93.7% [Kim et al, 2019]. This supports the use of MRI in identifying chronic degenerative changes rather than acute inflammation, but also highlights limitations in sensitivity with MRI.
        • A systematic review and meta-analysis by Almeida et al. highlighted that MRI shows high specificity (93.0% to 99.0%) for diagnosing complete tears of the LHBT, although sensitivity for partial tears and tendinosis is more variable (55.9% to 90.0%) [Almeida et al, 2024]. This variability underscores the importance of combining MRI findings with clinical evaluation for a comprehensive diagnosis.
  • The diagnosis of biceps tendinopathy is primarily clinical, supported by imaging and histologic findings. The absence of acute inflammation in histologic studies underscores the importance of focusing on degenerative changes when evaluating and managing this condition.

How to Distinguish Rotator Cuff and Biceps Tendon Tears?

  • Distinguishing between rotator cuff tears and biceps tendon tears can be challenging due to overlapping symptoms. However, specific clinical presentations, physical examination findings, and imaging studies can aid in differentiation.

    • Clinical Presentation:

      • Rotator Cuff Tears: Typically present with lateral shoulder pain, often woresened by overhead activities and night pain. Patients may report weakness, particularly with arm elevation and external rotation [Jain & Khazzam et al, 2024].

      • Biceps Tendon Tears: Present with anterior shoulder pain, often described as a deep, throbbing ache. Pain is exacerbated by activities involving shoulder flexion and supination [Churgay, 2009].

    • Physical Examination:

      • Rotator Cuff Tears: The physical exam tests to identify rotator cuff tears are different than for biceps tendon pathology. In addition, patients may experience muscle atrophy and weakness in abduction and external rotation are common [Jain & Khazzam et al, 2024].

      • Biceps Tendon Tears: The physical exam tests to identify biceps tendon pathology are different than for rotator cuff tears. Patients may also experience tenderness over the bicipital groove.

    • Imaging Studies:

      • Ultrasound is highly effective for both conditions. For biceps tendinopathy,
        ultrasound shows high sensitivity and specificity for detecting full-thickness tears and dislocations. For rotator cuff tears, ultrasound can visualize tendon integrity and muscle atrophy [Courage et al, 2023].

      • MRI provides detailed images of both the rotator cuff and biceps tendon. MRI is particularly useful for visualizing intra-articular pathology and associated labral tears [Canavan et al, 2024; Alraddadi et al, 2024].

    • Differential Injections:

      • Ultrasound-Guided Injections: Diagnostic injections can help localize the source of pain. Anesthetic injections into the subacromial space can relieve pain from rotator cuff pathology, while injections into the bicipital groove can confirm biceps tendon involvement [Churgay, 2009].

How do you Treat Biceps Tendon Pain?

Conservative Management

  • Rest and Activity Modification: Initial treatment for most tendinopathy often includes rest and avoiding activities that exacerbate symptoms, particularly overhead motions [Churgay, 2009; Nho et al, 2010].

  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs can help manage pain, although their role is more for symptomatic relief rather than addressing the underlying degenerative changes [Churgay, 2009; Nho et al, 2010].

  • Physical Therapy: A structured physical therapy program focusing on eccentric exercises has shown consistent effectiveness in managing tendinopathy-related pain and improving function. Eccentric loading exercises are particularly beneficial in promoting tendon healing and reducing pain [Irby et al, 2020; Kane et al, 2019].

  • Corticosteroid Injections: Ultrasound-guided corticosteroid injections into the biceps tendon sheath can provide short-term pain relief and improve function. These injections are more accurate and cause less discomfort when performed under ultrasound guidance compared to palpation-guided techniques.

    • A study by Yiannakopoulos et al. compared ultrasound-guided injections to palpation-guided injections for tendinosis of the long head of the biceps tendon. The study found that ultrasound-guided injections were more accurate, with a 100% accuracy rate compared to 68.18% for palpation-guided injections. Additionally, ultrasound-guided injections resulted in lower patient discomfort and faster procedure times, and the ultrasound-guided group demonstrated superior clinical improvement at both time points [Yiannakopoulos et al, 2020].

  • Platelet Rich Plasma (PRP) Injections: PRP therapy involves injecting a concentrated solution of platelets derived from the patient's own blood into the site of tendon injury. This solution contains several growth factors that promote healing, including platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), and transforming growth factor-beta (TGF-β)​. PRP shows promise in treating biceps tendon pathology, with evidence supporting its role in reducing pain and improving function.

    • In a case controlled study by Ashraf Elazab et al. (2021), 52 caese were divided into 2 equal groups and underwent a single ultrasound-guided PRP injection for long head biceps tendinitis compared to a placebo injection with xylocaine (local anesthetic). The authors found a significant improvement in both pain and shoulder function (measured by the Oxford Shoulder Score) following the PRP injection when compared to the control (placebo injection). These findings suggest that PRP can offer effective relief for biceps tendinopathy, especially for patients who have not responded to conservative treatments like physical therapy or anti-inflammatory medications​ [Ashraf et al, 2021].

    • In a randomized controlled trial by Singh and Singh (2024) a single ultrasound-guided platelet-rich plasma (PRP) injection was compared to corticosteroid injections for treating biceps tendinopathy in 32 athletes.​ Half the patients received a PRP injection and the other half received a corticosteroid injection. The results showed that while corticosteroid injections led to short-term improvements in pain and function the athletes who had a PRP injection demonstrated superior long-term benefits. At the 24-week follow-up, the PRP group exhibited greater improvements in both pain relief and shoulder function, supporting the hypothesis that PRP may offer more durable outcomes compared to corticosteroids [Singh & Singh, 2024].
    • A study by Moon et al. (2011) further supports these findings. In a randomized comparative study to study of platelet-rich plasma therapy (PRP) and prolotherapy for symptomatic long-head biceps tendinopathy 100 cases were followed for more than one year. The study found that there was no significant difference between the 2 groups in the first month after the procedure. However, at the 3, 6 and 12-month follow-up there was a significant improvement in pain and function with the PRP injection (p < 0.05) [Moon et al, 2011].
    • A pilot study by Ibrahim et al. (2012) investigated the use of PRP for biceps tendinopathy in 8 spinal cord injury (SCI) patients, a group known to experience high rates of shoulder pain due to increased reliance on manual wheelchairs. The authors reported positive results, with patients experiencing significant reductions in pain and improvements in shoulder function. The safety and efficacy observed in this pilot study further support the potential of PRP as a non-invasive treatment for chronic tendon pain [Ibrahim et al, 2012]​.

Surgical Management

  • Surgical management options for biceps tendon pathology include biceps tenotomy and tenodesis.

    • Biceps tenotomy is a surgical procedure is often performed under general anesthesia where the surgeon makes an incision and uses an arthroscope to view the inside of the shoulder joint. The long head of the biceps tendon is then identified and cut to release the tendon from its attachment at the top of the shoulder joint using an arthroscopic shaver or electrocautery device. Any remaining tendon stump is then debrided to prevent impingement or irritation.

      • Biceps tenotomy is often offered to patients who do not require high levels of arm strength for their daily activities

      • Tenotomy is associated with a higher incidence of cosmetic deformity, known as the "Popeye sign," due to the retraction of the biceps muscle and bulge of the muscle due to the tendon no longer being anchored to the shoulder.

      • Some patients may also experience cramping or a slight decrease in arm strength, especially when bending the elbow or turning the palm upward, which could affect day-to-day activities like lifting or twisting [Pozzetti Daou et al, 2021; Frank et al, 2018].

    • Biceps tenodesis is a surgical procedure under general anesthesia that involves making an incision over the front of the shoulder, and using an arthroscope (small camera) the surgeon detaches the biceps tendon from its attachment inside the shoulder joint. The tendon is then reattached to the upper part of the humerus (the bone of the upper arm) by drilling a hole and using anchors, screws or sutures to secure the tendon in a new position. Once secured, the incision is closed with stitches. Full recovery can take a few months, and following the rehabilitation plan is crucial for a successful outcome.

      • Like any surgery, biceps tenodesis carries risks, including:

        • Cramping: Some patients may experience cramping in the biceps muscle after surgery, which can be uncomfortable but is usually temporary. Specific percentages are not well-documented.

        • Residual Pain: Pain in the biceps groove can persist in some cases, even after successful surgery, occurring in about 10.8% to 12.9% of cases [McCrum et al, 2019].

        • Cosmetic Deformity: Known as the "Popeye deformity," this occurs in up to 6.8% of cases [Belk et al, 2021].
    • Studies suggest that tenodesis has a reduced risk of cosmetic changes and its potential for stronger long-term functional improvement, particularly in younger, more active individuals. However, tenodesis is a more involved surgery with longer operative times and a slightly higher chance of discomfort around the bicipital groove, especially with certain techniques like intracuff tenodesis.

References:

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  2. Alraddadi A, Aldebasi B, Alnufaie B, Almuhanna M, Alkhalifah M, Aleidan M, Murad Y, Almuklass AM, Ahmed AA. The association between a rotator cuff tendon tear and a tear of the long head of the biceps tendon: Chart review study. PLoS One. 2024 Mar 11;19(3):e0300265.
  3. Ashraf E, Ahmed S. Is Single Platelet Rich Plasma Injection Effective for Management of Long Head of Biceps tendinitis: A Case Control Study. Ortho & Rheum Open Access J. 2021; 17(4): 555966.
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  5. Belk JW, Kraeutler MJ, Houck DA, Chrisman AN, Scillia AJ, McCarty EC. Biceps tenodesis versus tenotomy: a systematic review and meta-analysis of level I randomized controlled trials. J Shoulder Elbow Surg. 2021 May;30(5):951-960.
  6. Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosisof biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009 Sep;37(9):1840-7.
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  31. Yiannakopoulos CK, Megaloikonomos PD, Foufa K, Gliatis J. Ultrasound-guided versus palpation-guided corticosteroid injections for tendinosis of the long head of the biceps: A randomized comparative study. Skeletal Radiol. 2020 Apr;49(4):585-591.

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