Biceps tendinopathy describes a painful inflammation or degeneration of the tendon of the long head of the biceps. (1,2) The term “tendinopathy” may suggest either an inflammatory or degenerative origin. (3) In the case of a recent insult, inflammation (tendinitis) may be a valid explanation. However, current evidence suggests that many cases of tendinopathy occur without inflammation and are the result of chronic overload, which leads to microscopic tearing, failed healing and degenerative changes within the tendon. (3) Injuries that have been present over three months consistently demonstrate fibrosis and degeneration with very little actual inflammation (3).
Who is most likely to have a biceps tendinopathy?
Biceps tendinopathy is most common in young adults between the ages of 18 and 35. (12) The condition often results from repetitive overhead activity, including throwing, swimming, gymnastics, martial arts, racquet sports, and contact sports (12-13). Subacromial impingement is the most common cause of shoulder complaints and may lead to a plethora of problems, including biceps tendinitis (14). In fact, 95% of biceps tendinopathy patients have “shoulder impingement” as their primary diagnosis. (15) Because of common etiologies, biceps tendinopathy rarely occurs in isolation and over 90 percent co-exist with other impingement related pathologies of the shoulder such as rotator cuff tendinopathy/tears, labral tears, and shoulder instability (13,15,16). Additional risk factors for the development of biceps tendinopathy include repetitive shoulder flexion (lifting arm straight in front of you) or elbow bending, repetitive overhead activity, improper lifting technique, shoulder girdle muscle imbalances, poor posture, inflexibility, scapulothoracic or glenohumeral instability, repetitive overload, trauma, and osseous anatomical abnormalities that narrow the bicipital groove, including fracture, osteoarthritis, and congenital variations (17). Symptoms:
Patients with bicipital tendinopathy often complain of a deep throbbing ache over the anterior shoulder (4,18). Symptoms are often provoked by repetitive overhead activity (18,19). Symptoms increase when initiating activity (18). Nocturnal symptoms are common, particularly when sleeping on the affected shoulder (18,19). Patients often report mild relief from palliative measures, including heat, ice, stretching, and massage (18).
Biceps tendons are one of the more common tendons to rupture. Tendon rupture is suggested by a history of a painful audible pop followed by relief. Risk factors associated with the biceps tendon rupture include chronic tendinopathy, concurrent rotator cuff tear, contralateral biceps tendon rupture, age over 40, poor conditioning, and the presence of a rheumatologic disease (19).Bruising & swelling with a visible bulge (Popeye deformity) where the muscle has retracted toward the elbow indicates tendon rupture. (19,58) Clinical evaluation of biceps tendinopathy will often demonstrate limited range of motion. Popping, catching, or locking movements during active range of motion testing may suggest a labral injury (20). Palpation should elicit the most characteristic finding of tenderness in the rotator interval and bicipital groove (1,21,22).
Do I need imaging?
Plain film (x-ray) imaging is of little value for the assessment of the biceps tendon but may identify osseous sources of impingement or other bony pathology. Ultrasound is a useful imaging technique for the biceps tendon (39-45). MRI may help identify ruptures of the long head of the biceps tendon or concurrent pathology, including rotator cuff lesions and labral tears (46,47). Overall, the evidence suggests that ultrasound and MRI are similar for assessing patients with suspected biceps abnormalities (74-76). Due to similar mechanisms of injury and indistinguishably blended anatomy, lesions of the bicep tendon are difficult to differentiate from rotator cuff pathology or labral tears (48). Biceps tendinopathy often co-exists with these and other pathologies of the shoulder (15,19,48).
What are the best treatment options for a biceps tendonopathy?
Conservative care is the most appropriate management for the majority of biceps tendinopathy patients (49).
The first phase of treatment is directed at pain relief and restoration of normal motion (51,52). Patients should limit activities that require repetitive overhead activity, elbow flexion, or forearm supination. Patients should specifically avoid military presses, upright rows, and wide-grip bench presses (52). Therapeutic modalities, including ice, heat, ultrasound, microcurrent, or e-stim may be appropriate to control symptoms as needed (52). The goal of rehab should be to establish a full, balanced, pain-free range of motion. (53)
Soft tissue techniques may include transverse friction massage or IASTM over the biceps tendon. Myofascial release and stretching exercises may be appropriate for the biceps, cervical spine, shoulder, and periscapular musculature.
Mobility exercises may include pendulum circumduction, wall walking, first phase of treatment should include early scapular stabilization exercises, via activation of the lower trapezius and serratus anterior. Examples of these exercises include YTWL and scapular protraction. As patient’s recover, strengthening may progress from isometric to concentric, then eccentric, and finally, sports specific rehab (51). Eccentric loading for the management of tendinopathies is a proven beneficial strategy and may be implemented as the patient recovers (51,54,71,72). Advanced strengthening exercises may include a bear hug, reverse fly, and resisted internal/external rotation at 90 degrees of abduction (52).
Limited cervicothoracic mobility, including a forward flexed posture, limits normal scapulohumeral rhythm and predisposes the shoulder to impingement-related disorders. There is evidence to suggest that cervicothoracic and thoracic spine manipulation is appropriate for patients with shoulder pain (33,55-57). Spinal manipulation may help decrease shoulder pain while improving mobility and function (33,55).
Medical management of biceps tendinopathy may include NSAIDs (66).
Ultrasound-guided, local anesthetic injection into the biceps tendon sheath may provide palliative relief for patients with primary biceps tendinitis, although injections directly into the tendon may increase the risk of rupture (59-63). Ultrasound guidance may produce up to a five-fold increase in pain relief versus non-ultrasound guided (64,65). Surgery is generally not considered for biceps tendinopathy unless prolonged (greater than three months) conservative measures have failed (66). Even in cases of tendon rupture, the value of surgery is questionable. Patients with complete rupture of the long head of the biceps tendon demonstrate 11-16% diminished strength in elbow flexion, forearm supination, and shoulder abduction. (67) Strength losses post-surgical repair range from 7-20 percent (67). Surgical repair (tenodesis) is usually reserved for younger individuals (<60), athletes, and manual workers (67-70).
At Creekside Chiropractic & Performance Center, we are highly trained to treat biceps tendonitis and tendonopathy. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor by the Sheboygan Press.
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