Biceps Tendinopathy

Biceps tendinopathy is degeneration and irritation of the long head of the biceps tendon. It is a common source of anterior shoulder pain, but it rarely occurs alone. Rotator cuff disease accompanies it in about half of patients, and subscapularis tears and pulley lesions are frequent partners.

The tendon arises from the superior labrum and supraglenoid tubercle and runs inside the joint. It then turns under a pulley formed by the coracohumeral ligament, superior glenohumeral ligament and fibres of the subscapularis before entering the bicipital groove.

Causes and associations:

• Repetitive overhead or lifting activity
• Narrow or shallow bicipital groove
• Pulley failure with tendon subluxation
• Superior labral lesions
• Inflammatory arthropathy and diabetes

The pathology is tendinosis with disorganised collagen, rather than classic inflammation. In its advanced form the tendon thickens and becomes trapped at the groove entrance (hourglass biceps), which blocks glide and can cause a painful block to elevation. Most patients improve with structured exercise. Complications are partial tear, rupture, subluxation and secondary stiffness.

• Anterior shoulder pain over the groove, worse with overhead reaching, lifting and pulling, and at night
• Tenderness 3 to 7 cm below the front of the acromion, which moves with arm rotation
• Pain with resisted forward flexion of the straight supinated arm (Speed test) and with resisted forearm supination at 90 degrees of elbow flexion (Yergason test)
• A palpable or audible click as the tendon subluxates in pulley injury
• Red flags: sudden pop with arm bruising and a lump in the biceps (rupture), weakness of cuff muscles, unrelenting night pain, neck pain with arm radiation, fever

• Clinical diagnosis from groove tenderness and the provocative tests.
• Ultrasound: fluid in the tendon sheath, tendon thickening, loss of fibrillar pattern, and dynamic subluxation on rotation. It also shows a cuff tear.
• MRI or MR arthrography: tendon signal change, medial subluxation, pulley and subscapularis integrity, labral involvement and cuff tear.
• Radiographs (anteroposterior, scapular Y, axillary, and a groove view): spurs in the groove and acromial shape.
• Diagnostic injection: lidocaine 1% 3 to 5 mL into the sheath under ultrasound relieves pain within minutes when the biceps is the source.

Differentials: rotator cuff tear, subacromial impingement, superior labral tear, adhesive capsulitis, acromioclavicular arthritis, cervical radiculopathy, glenohumeral arthritis.

• Activity modification for 2 to 4 weeks: avoid repeated overhead lifting and heavy pulling.
• Analgesia: paracetamol 1 g orally every 6 hours (maximum 4 g a day), and ibuprofen 400 mg orally every 8 hours with food for up to 7 days. Avoid ibuprofen in peptic ulcer, renal impairment and heart failure.
• Physiotherapy for 12 weeks: scapular stabilisation, cuff strengthening with elastic band (3 sets of 10 to 15 repetitions daily), posterior capsule stretching, and eccentric biceps loading.
• Sheath injection: triamcinolone acetonide 20 to 40 mg with lidocaine 1% 3 mL into the sheath, not the tendon, under ultrasound guidance. Maximum two injections, 3 months apart (tendon rupture risk).
• Surgery after 6 months of failed treatment:
  • Arthroscopic tenotomy: quick, with a lower rehabilitation burden, but causes a cosmetic Popeye deformity in 20 to 70% and cramping pain in some. Suited to older, low demand or heavier patients.
  • Tenodesis (open subpectoral or arthroscopic) with an 8 mm interference screw or suture anchor: preferred in patients under 60, manual workers and athletes. Complications: humeral fracture at the screw site, infection, nerve injury, failed fixation.
  • Repair the cuff and pulley at the same operation.
  • Cefazolin 2 g IV 30 to 60 minutes before incision (3 g if over 120 kg).
• Postoperative: sling for 2 to 4 weeks, avoid resisted elbow flexion and supination for 6 weeks after tenodesis, and return to heavy lifting at 4 to 6 months.

Follow up at 6 and 12 weeks. Counsel on load management and on the likelihood of recovery with exercise alone.