Continuing Education Activity

The main function of the biceps muscle is forearm supination and elbow flexion. The biceps also contribute 10 percent of the total power in shoulder abduction when the arm is in external rotation. Consequently, biceps tendinitis, a condition describing inflammation of the tendon that attaches the biceps muscle to the bone, can impair patients' ability to perform many routine activities. This activity reviews the presentation, evaluation, and treatment of biceps tendinitis and underscores the importance of an interprofessional team approach to its management.

Objectives:

• Review the etiology of biceps tendinitis.
• Describe the history and physical exam of a patient with biceps tendinitis.
• Summarize the treatment options for biceps tendinitis.
• Describe how enhanced coordination of the interprofessional team can lead to more rapid recognition of biceps tendinitis and subsequently improve the evaluation, enhancing detection of pathology and allowing for treatment when indicated.

Access free multiple choice questions on this topic.

Introduction

The long head of the biceps (LHB) brachii tendon originates at the supraglenoid tubercle and superior glenoid labrum. The labral origin is mostly posterior in more than half of cases. Within the joint, the tendon is extrasynovial and courses obliquely toward the bicipital groove. The LHB tendon distally joins the short head of the biceps (SHB) tendon as both transition into their respective muscle bellies in the central third of the upper arm and, after crossing the volar aspect of the elbow, insert on the radial tuberosity and medial forearm fascia. The latter occurs via the bicipital aponeurosis.[1]

The blood supply to the LHB tendon occurs via the anterior humeral circumflex artery. Results from studies demonstrated 2 critical areas of avascularity of the LHB tendon, located on the deep undersurface of the tendon in the groove and proximally near its insertion at the superior glenoid.[2] The bicipital groove is an anatomic landmark that sits between the greater and lesser tuberosities and serves as a critical location of proximal biceps stability. The soft-tissue components of the groove form a tendoligamentous sling that supports the LHB tendon. Components include portions of the rotator cuff muscles (subscapularis and supraspinatus), coracohumeral ligament (CHL), and the superior glenohumeral ligament (SGHL).[2]

Biomechanically, the long head of the biceps tendon has a controversial role in the dynamic stability of the shoulder joint. Results from mostly cadaveric biomechanical studies and animal models demonstrated that the tendon at least plays a passive stabilizing role in the shoulder. Neer proposed in the 1970s that the stabilizing role of the long head of the biceps tendon varied with elbow position.[3] Results from several subsequent studies refuted the theory that the long head of the biceps tendon had any active shoulder-stabilizing effect. Jobe and Perry evaluated biceps activation during the throwing motion in athletes. The authors reported that peak muscle stimulation occurred during elbow flexion and forearm deceleration, with very little proximal biceps activity in the early phases of throwing.[4][5][6] Thus, in most healthy patient populations, the long head of the biceps tendon plays a negligible role in the dynamic stability of the shoulder. The main function of the biceps muscle is forearm supination and elbow flexion. The biceps also contributes 10% of the total power in shoulder abduction when the arm is in external rotation.[2]

Etiology

Biceps tendinitis is a clinical condition characterized by inflammatory tenosynovitis, most commonly affecting the tendinous portion of the long head of the biceps (LHB) tendon as it courses within the bicipital groove of the proximal humerus. The continuum of clinical pathology ranges from acute inflammatory tendinitis to degenerative tendinopathy. Primary bicipital tendinitis is much less common than secondary cases associated with concomitant primary shoulder pathologies. The etiologies of primary bicipital tendinitis are less well understood than those of the more common secondary presentations. A particular subset of patients with primary isolated biceps tendinitis has been recognized among younger, athletic patients. Provocative sports include baseball, softball, and volleyball. Beyond this athletic cohort, only a few case reports in the literature highlight patients presenting with spontaneous LHB tendon ruptures secondary to medical comorbidities.

Secondary cases are much more common and have been described in the literature with increasing frequency dating back to at least the early 1980s. In 1982, Neviaser et al demonstrated the relationship between increasing LHB tendon inflammatory changes and increasing severity of rotator cuff tendinopathy. Other associated shoulder pathologies include:

• Rotator cuff tendinitis and tendinopathy
• Subscapularis injuries
• LHB tendon instability/dislocation

  • Often seen in association with subscapularis injuries/tears
• Direct or indirect trauma
• Inflammatory conditions
•  Internal impingement of the shoulder (thrower’s shoulder)

  • Glenohumeral internal rotation deficit (GIRD)
  • Superior labral lesions (the peel-back mechanism)
• External impingement/subacromial impingement syndrome (EI/SIS)
• Glenohumeral arthritis [2][7][8]

Epidemiology

Primary LHB tendinitis represents about 5% of cases of proximal biceps pathology. Although much less common, primary isolated cases are typically observed in young athletes participating in baseball, softball, volleyball, gymnastics, or swimming.[8][9][10] The vast majority of cases are associated with the aforementioned shoulder pathologies. Most commonly, LHB tendinopathy occurs in association with rotator cuff pathology, external impingement or subacromial impingement syndrome, or in tandem with subscapularis injuries. In rotator cuff tear cases, studies have shown that 90% had concomitant LHB tendinopathy and 45% had additional LHB instability.[11][12]

Pathophysiology

Tendinopathic Cascade

The pathophysiology of LHB tendinitis and tendinopathy begins with early tenosynovitis and inflammation secondary to repetitive traction, friction, and shoulder rotation. Inflammation develops early in the tendinous portion of the LHB tendon in the bicipital groove. The tendon increases in diameter secondary to swelling or associated hemorrhage, further compromising it as it becomes mechanically irritated within its confined space.

The resultant increased pressure and specific sites of traction predispose the tendon to pathologic shear forces. In addition, the sheath of the biceps tendon is a direct extension of the synovial lining of the glenohumeral joint. Thus, concomitant or preexisting rotator cuff pathology can directly compromise the LHB tendon itself. In the early stages of the disease, the LHB tendon remains mobile in the bicipital groove.

As the pathophysiology escalates, LHB sheath thickening, fibrosis, and vascular compromise ensue. The LHB tendon undergoes degenerative changes and associated scarring, fibrosis, and adhesions that eventually compromise LHB tendon mobility. Consequently, the tendon becomes pathologically anchored in the groove, further exacerbating potential points of traction and increasing the overall shear forces on the LHB tendon along its course. In advanced, end-stage conditions, the LHB tendon can eventually rupture at its origin near the superior glenoid tubercle, or as it exits the bicipital groove near its musculotendinous junction.[2]

Overhead Throwing

During an overhead throw, such as pitching in baseball, the thrower’s shoulder is brought into a position of maximum shoulder abduction and external rotation during the late cocking phase. Biceps injuries occur in this position secondary to the peel-back phenomenon. Subsequently, the biceps muscle eccentrically contracts to decelerate elbow extension during the follow-through phase of throwing.[8][9][10]

Histopathology

The histologic severity of LHB tendon disease does not correlate with the pathology observed on MRI or during direct intraoperative inspection. Furthermore, results from other studies suggest that symptom duration does not correlate with histologic severity. Additionally, the more proximal zones of the LHB tendon (ie, the intra-articular and bicipital groove portions) consistently demonstrate higher histologic grades of tendinopathy compared with tissue specimens examined from more distal LHB tendon zones.[13][14][15] While histologic grading of the severity of tendinopathic changes is distinct from the clinical presentation and MRI and/or intraoperative findings, there are noteworthy pathologic patterns associated with increasing grades of tendinopathic severity.[13][14][15]

Grade 0

• Tenocytes are normal in appearance
• Myxoid degenerative material is absent
• Collagen remains arranged in tight, cohesive bundles
• Blood vessels are arranged inconspicuously between collagen bundles

Grade 1

• Tenocytes are rounded
• Myxoid degenerative material present in small amounts between collagen bundles
• Collagen remains arranged in discrete bundles, but a slight separation between bundles becomes apparent
• Capillary clustering is evident (< 1 cluster per 10 high-power fields)

Grade 2

• Tenocytes are rounded and enlarged
• Myxoid degenerative material evident in moderate to large amounts
• Collagen bundles lose discrete organization as the separation between individual fibers and bundles increases
• Capillary clustering is increased (1 to 2 clusters per ten high-power fields)

Grade 3

• Tenocytes are rounded and enlarged with abundant cytoplasm and lacuna
• Myxoid degenerative material abundant
• Collagen disorganized, loss of microarchitecture
• Capillary clustering is increased (> 2 clusters per 10 high-power fields)

Other Changes Associated With T endinopathy

• Tenosynovium:

  • Irrespective of histologic grade of tendinopathy, the surrounding bicipital sheath/synovium demonstrates varying degrees of synovial hypertrophy, hyperplasia, and proliferation
• Low-grade degenerative tendinopathy:

  • Total cellularity (cell density, cells/mm): minimal increase
  • Apoptotic index (% relative to the total number of cells counted): minimal increase
• Moderate grade degenerative tendinopathy:

  • Total cellularity (cell density, cells/mm): peak increase
  • Apoptotic index (% relative to the total number of cells counted): moderate increase
• Severe grade degenerative tendinopathy:

  • Total cellularity (cell density, cells/mm): decreases
  • Apoptotic index (% relative to the total number of cells counted): peak increase

Histologic studies have consistently reported that, irrespective of patient age, symptom severity, or duration, acute inflammatory changes are rarely evident on histologic specimen analysis.

History and Physical

A comprehensive history should be obtained by clinicians evaluating patients presenting with acute or chronic shoulder pain. Characteristics of proximal biceps tendinitis include the following:

• Atraumatic, insidious onset of anterior shoulder pain
• Symptom exacerbation with overhead activities
• Pain radiating down the anterior arm from the shoulder
• Clicking or audible popping can be reported in the setting of proximal biceps instability
• Pain at rest, pain at night
• History of current participation in sports, especially baseball, volleyball, and other overhead sports
• History of current manual or physical laborer occupations

In addition, a thorough history includes a detailed account of the patient’s occupational history and current employment status, hand dominance, history of shoulder or neck injury or trauma, and any relevant surgical history.

C-Spine and Neck Examination

Coexisting cervical radiculopathy should be ruled out in any situation in which neck or shoulder pathology is being considered. Clinicians should evaluate neck posturing, muscular symmetry, palpable tenderness, and active and passive range of motion (ROM). Special tests that are helpful in this regard include the Spurling maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular examination.[16]

Shoulder Examination

Clinicians must assess the shoulder girdle as a whole to evaluate symmetry, shoulder posture, and muscle bulk. Scapular winging should also be ruled out. The skin should be observed for the presence of any previous surgical incisions, lacerations, scars, erythema, or induration. In the setting of proximal biceps pathology, especially in traumatic or spontaneous LHB tendon ruptures, patients typically exhibit significant ecchymosis over the biceps brachii muscle, and an associated Popeye deformity is characteristic of a complete rupture. The latter is more readily appreciated in fit or thin patients and can be a more subtle finding in patients with large body habitus. Thus, a comparison to the contralateral extremity is helpful.[17][18][19][20][21]

After the observational component of the physical examination, active and passive ROM are documented. In both primary and secondary proximal biceps tendinitis cases, full ROM should be observed. In the absence of advanced glenohumeral arthritic changes, limited passive ROM is considered diagnostic for adhesive capsulitis.

The clinician can assess motor strength grading for C5 to T1 nerve roots in addition to specific rotator cuff muscle strength testing. Specifically, rotator cuff strength and pathology can be assessed via the following examinations: 

Proximal Biceps Provocative Testing

Multiple focused physical examination maneuvers have been reported in the literature. Specific physical examination maneuvers target either LHB pathology localized to the bicipital groove or more proximally near the tendon origin at the supraglenoid tubercle. Differentiating LHB tendon–associated pain from other associated shoulder pathologies, including pain secondary to acromioclavicular joint pathologies, is important.[22][23]

Bicipital groove palpation: Direct palpation over the patient’s bicipital groove elicits a painful response in the setting of pathology.

Speed test: A positive test consists of pain elicited in the bicipital groove when the patient attempts to forward-elevate the shoulder against the examiner's resistance; the elbow is slightly flexed and the forearm is supinated.

Uppercut test: The involved shoulder is positioned at neutral, the elbow is flexed to 90°, the forearm is supinated, and the patient makes a fist. The examiner instructs the patient to perform a boxing uppercut punch while placing the examiner’s hand over the patient’s fist to resist the upward motion. A positive test occurs when the patient experiences pain or a painful pop over the anterior shoulder near the bicipital groove region.

Yergason test:

The arm is stabilized against the patient’s trunk, and the elbow is flexed to 90°. The involved shoulder is positioned at neutral, the elbow is flexed to 90°, the forearm is supinated, and the patient makes a fist. The examiner instructs the patient to perform a boxing uppercut punch while placing the examiner’s hand over the patient’s fist to resist the upward motion. A positive test occurs when the patient experiences pain or a painful pop over the anterior shoulder near the bicipital groove region, with the forearm pronated. The examiner manually resists supination while the patient externally rotates the arm against resistance. A positive test is noted if the patient reports pain over the bicipital groove and/or subluxation of the LHB tendon. In addition to eliciting bicipital groove pathology, the clinician should also attempt to examine for possible associated labral and/or rotator cuff pathologies.

Acromioclavicular Joint Provocative Testing

[24] Observation and direct palpation: Patients presenting with chronic acromioclavicular joint pain or arthritic pathology often have clinically obvious acromioclavicular joint hypertrophy that can be appreciated with observation or direct palpation over the joint.

Crossbody adduction: The examiner may find it helpful to localize the acromioclavicular joint with direct palpation. Subsequently, the examiner brings the shoulder into approximately 90° of flexion in front of the scapular plane, and a positive test is defined as patient-reported symptom reproduction when the arm is brought into cross-body adduction positions. The physician should be able to discern the exact location of pain reproduction with the cross-body adduction maneuvers.[24][25]

Superior Labrum Anterior-Posterior Lesions

O’Brien test or active compression test:

The patient is standing, and the arm of interest is positioned at 90° of forward flexion, 10° of adduction, and internal rotation, with the first digit pointing toward the floor. The examiner places the examiner’s hand over the patient’s elbow while instructing the patient to resist the examiner’s downward force applied to the arm. This maneuver is repeated with the patient’s arm rotated so that the palm faces the ceiling. A positive test is denoted by pain located at the joint line during the initial maneuver (first digit down and internal rotation) in conjunction with reported improvement or elimination of the pain during the subsequent maneuver (palm up and external rotation).

Anterior slide test: The patient stands with the hand of the involved arm resting on the ipsilateral hip, the thumb pointing posteriorly. The examiner places one hand on the joint line of the shoulder and the other hand on the elbow. The examiner then applies an axial load in an anterosuperior direction from the elbow to the shoulder. A positive test includes pain or a painful click on the anterior or posterior joint line.

Modified O’Driscoll test or modified dynamic labral shear test: The patient stands with his or her involved arm flexed 90 degrees at the elbow and the shoulder abducted in the scapular plane to above 120°. The examiner then applies terminal external rotation until resistance is appreciated. Next, the examiner applies a shear force through the shoulder joint by maintaining external rotation and horizontal abduction and lowering the arm from 120° to 60° abduction. A positive test result includes a reproduction of the pain and/or a painful click or catch in the joint line along the posterior joint line between 120° and 90° of abduction.

Rotator Cuff Muscle Testing

Supraspinatus 

• Jobe test: A positive test result is pain or weakness with resisted downward pressure while the patient’s shoulder is at 90° of forward flexion and abduction in the scapular plane with the thumb pointing toward the floor. 
• Drop arm test: The patient’s shoulder is brought into a position of 90° of shoulder abduction in the scapular plane. The examiner initially supports the limb, then instructs the patient to slowly adduct the arm to the side of the body. A positive test includes the patient’s inability to maintain shoulder abduction or to adduct the arm to the side of the trunk in a controlled manner.

Infraspinatus 

• Strength testing: This is performed with the shoulder positioned against the side of the trunk, the elbow flexed to 90°, and the patient is asked to externally rotate the arm while the examiner resists the movement.
• External rotation lag sign: The examiner positions the patient’s shoulder in the same position, and while holding the wrist, the arm is brought into maximum external rotation. The test is positive if the patient’s shoulder drifts into internal rotation once the examiner removes the supportive ER force at the wrist.

Teres Minor

Strength testing: This is performed with the shoulder at 90 ° of abduction and the elbow flexed to 90°. Teres minor is best isolated for strength testing in this position while external rotation is resisted by the examiner.

• Hornblower sign: The examiner positions the shoulder in the same position and then maximally externally rotates it under support. A positive test occurs when the patient is unable to maintain this position and the arm drifts into IR after the examiner removes the supportive externally rotated force.

Subscapularis 

• Internal rotation lag sign: The examiner passively moves the patient’s shoulder posteriorly (about 20 degrees of extension) while the elbow is flexed to 90°. The examiner passively internally rotates the shoulder by lifting the dorsum of the hand off the patient’s back while supporting the elbow and wrist. A positive test result occurs when the patient is unable to maintain this position once the examiner releases support at the wrist (ie, the arm is not maintained in internal rotation, and the dorsum of the hand drifts toward the back)
• Passive external rotation range of motion: A partial or complete tear of the subscapularis can manifest with an increase in passive external rotation compared with the contralateral shoulder.
• Lift-off test: This test is more sensitive/specific for lower SubSc pathology.  In the same position as the IR lag sign position, the examiner places the patient’s dorsum of the hand against the lower back and then resists the patient’s ability to lift the dorsum of the hand away from the lower back.
• Belly press: This test is more sensitive/specific for upper subscapularis pathology. The examiner has the patient’s arm at 90° of elbow flexion, and internal rotation testing is performed by the patient pressing the palm of his/her hand against the belly, bringing the elbow in front of the plane of the trunk. The examiner initially supports the elbow, and a positive test occurs if the elbow is not maintained in this position when the examiner removes the supporting force.

External impingement:

• Neer impingement sign: Positive test results occurs if the patient reports pain with passive shoulder forward flexion beyond 90°.
• Neer impingement test: Positive test occurs after the examiner administers a subacromial injection, and the patient reports improved symptoms when repeating forced passive forward flexion beyond 90°.
• Hawkins test: A positive test result occurs when the examiner passively positions the shoulder and elbow at 90 degrees of flexion in front of the body; the patient will report pain when the examiner passively internally rotate the shoulder. 

Internal impingement:

• Internal impingement test: The patient is placed supine, and the shoulder is brought into terminal abduction and external rotation. A positive test result consists of reproducing the patient’s pain.

Evaluation

Radiographic imaging should be obtained in all patients with acute or chronic shoulder pain.

Radiographs

Recommended imaging includes a true anteroposterior (AP) image of the glenohumeral joint (ie, the Grashey view). The true AP image is obtained with the patient rotated 30° to 45° from the cassette in the coronal plane. Alternatively, the beam can be rotated while the patient remains neutral in the coronal plane. The distance between the acromion and the humeral head (ie, the acromiohumeral interval) can be calculated. The reference interval is 7 to 14 mm, and it is decreased in cases of advanced degenerative arthritis and rotator cuff arthropathy (RCA). Other standard views include the lateral (scapular Y) view and the axillary view. Routine radiographs are recommended, but in most cases of LHB tendinitis without coexisting pathologies, they will be normal.[2]

Ultrasonography

Ultrasonography is highly operator-dependent but is often touted as a fast, cost-effective tool for diagnosing LHB tendon pathology. Characteristic findings include tendon thickening, tenosynovitis or hypertrophy of the synovial sheath, and fluid surrounding the tendon in the groove. The ability to perform a dynamic examination increases the sensitivity and specificity for detecting subtle instability. The diagnostic accuracy of ultrasonography in detecting LHB pathology ranges from 50% to 96% (sensitivity) and 98% to 100% (specificity) when compared with magnetic resonance arthrography (MRA).[2]

Magnetic Resonance Imaging/M agnetic Resonance Arthrography 

MRI is useful for evaluating the LHB tendon, bicipital groove, and any fluid or edema that may indicate pathology. MRI is most beneficial in delineating other associated shoulder pathologies; however, MRI-suspected pathology has poor concordance with intraoperative findings or histologic grades of biceps tendinopathy.[2]

MRI is useful in evaluating the LHB tendon’s position in the bicipital groove. Absence of the tendon within the groove would suggest subluxation or dislocation. In these cases, careful attention should be paid to evaluating for concomitant subscapularis pathology. Other associated shoulder pathologies and rotator cuff integrity can also be evaluated with MRI. Other common sources of acute or chronic shoulder pain can be evaluated on MRI, including subdeltoid or subacromial bursitis and acromioclavicular joint pathology and morphology. A systematic approach to reviewing shoulder MRI is important, especially when correlating the MRI findings with the patient-reported symptoms and clinical examination. The addition of intravenous contrast dye (MR arthrography) is sensitive but only moderately specific for LHB tendon pathology. While a standard MRI series can be valuable for detecting fluid surrounding the LHB tendon as it courses through the bicipital groove, the administration of contrast dye is a confounding variable that inherently limits the specificity of this pathologic finding.

Treatment / Management

Nonoperative Management

The initial management of LHB tendinopathy is nonsurgical. A period of rest and activity modification is beneficial in the acute setting, coupled with nonsteroidal anti-inflammatory drugs (NSAIDs).

Physical therapy: Successful physical therapy regimens target the underlying source(s) contributing to the LHB tendon pathology. Potential factors predisposing to biceps-related shoulder injuries include glenohumeral internal rotation deficit (GIRD) in overhead-throwing athletes and baseball pitchers, poor trunk control, scapular dyskinesia, and internal impingement. Strengthening protocols should focus on restoring muscle balance across the shoulder girdle, including rotator cuff and periscapular muscle strengthening programs. Focused stretching on the anterior shoulder structures, including pectoralis minor, should also be considered. Other modalities, such as dry needling, have demonstrated promise in preliminary animal studies.[2]

Injections

Corticosteroid injections are considered in the setting of persistent symptoms despite the aforementioned therapies. There is some controversy regarding the technique used (ultrasound-guided versus blind injection) and the exact injection site (subacromial, intra-articular, bicipital groove/sheath). Theoretically, in the setting of concomitant shoulder pathologies, an intra-articular injection would also reach the LHB tendon in the bicipital groove, as the sheath is contiguous with the glenohumeral joint synovial tissue.[26][27][28]

Direct injection is targeted to the sheath itself, not directly to the LHB tendon. Although not definitively documented, an intratendinous LHB tendon injection may predispose the patient to tendon rupture. In results from a 2011 randomized controlled trial  comparing injection accuracy (with post-injection CT imaging to confirm injection placement by location) of ultrasound-guided versus blind bicipital sheath injections at their location in the groove. Potential injection location results included (1) solely in the tendon sheath, (2) inside the tendon, in the tendon sheath, and surrounding (but outside) the tendon sheath, and (3) confined to only the area outside the tendon sheath. The ultrasound-guided injections achieved 87% accuracy in targeting the tendon sheath alone (location "1"). By stark contrast, the blind injection was accurate only 27% of the time, and in one-third of cases, the tendon itself and the entire bicipital sheath were missed altogether.

Surgical Management

For this review, the management of superior labrum anterior-posterior injuries will not be discussed.

Indications for surgical management include:

• Intraoperative findings of an inflamed tendon (ie, the lipstick lesion), significant fraying, tearing, or hypertrophy
• Partial-thickness tears of the LHB tendon (>25% to 50%)
• Medial LHB subluxation
• LHB subluxation with associated subscapularis tear, or bicipital groove soft tissue compromise

Surgical Techniques

Biceps tenotomy:  Provides reproducible results in terms of pain relief and minimal postoperative rehabilitation.[2] The technique involves an initial diagnostic arthroscopy. The glenohumeral joint is inspected for any coexisting clinical pathology. The biceps tendon is examined under direct traction to visually inspect the intertubercular groove portion, which is a prime location of pathology. Next, a probe is used to evaluate the LHB tendon stability in the bicipital groove. Stability can be further assessed by internally rotating the arm and evaluating for any medial/inferior subluxation of the LHB tendon. In the setting of LHB tendon instability, this maneuver will lead to tendon entrapment within the joint. The entrapment is relieved with external rotation of the arm.

Arthroscopic inspection of the tendon allows for the estimation of the relative percentage of the LHB tendon that is compromised. A popular classification system used for the intraoperative grade corresponding to the degree of LHB tendon macroscopic pathology is the Lafosse grading scale:

• Grade 0: Normal tendon
• Grade 1: Minor lesion (partial, localized areas of tendon erosion/fraying, focal areas affect <50% of the tendon width)
• Grade 2: Major lesion (extensive tendon loss, compromising >50% of the tendon width)[29]

Some surgeons solely debride the tendon in the setting of <50% tendinous compromise. Arthroscopic biceps tenotomy is performed by releasing the tendon as close as possible to the superior labrum. As long as the tendon is free from intimate soft tissue adhesions to surrounding structures, the tendon should retract distally toward the bicipital groove. If adhesions are present, all efforts should be made to mobilize the tendon to allow retraction following the tenotomy. In cases where the LHB tendon is particularly hypertrophic and scarred against other soft tissue structures in the joint, this can be a potential source of postoperative pain.

Biceps tenodesis

• The preferred technique in younger patients, athletes, laborers, and those patients specifically concerned with postoperative cosmetic deformity
• Optimizes the length-tension relationship of the biceps muscle; mitigates postoperative risk of muscle atrophy, fatigue, and cramping [2][30]

Various locations for the tenodesis itself, in addition to the fixation technique used, provide equivalent results in terms of patient satisfaction and clinical outcomes. Following a standard diagnostic arthroscopy, a spinal needle is used to tag the tendon near its entrance into the bicipital groove. Once this is tagged with Fiberwire, the tenotomy is performed, and the residual stump is shaved back to the superior labrum.

Next, the arthroscope is introduced into the subacromial space, and the tagging sutures help localize the residual LHB tendon. The bicipital groove is then opened up with a cautery device until the LHB tendon is visualized. Following mobilization of the tendon to the medial aspect of the bicipital groove, the osseous groove is cleared of all soft tissue in preparation for fixation. One technique involves placing the interference screw approximately 1cm distal to the superior extent of the groove. During the fixation of the tendon, care is taken to use an arthroscopic grasper to maintain ideal tension on the proximal extent of the LHB tendon. Once fixation is complete, any residual tendon that remains prominent from the fixation point is carefully resected.

An alternative to the arthroscopic (or suprapectoral) tenodesis procedure is the open subpectoral approach. Several studies have compared outcomes between the all-arthroscopic and open subpectoral approaches. Although advocates of the latter approach cite the theoretical advantage of completely removing the LHB tendon from the bicipital groove, most studies report similar patient-reported outcomes and no differences in pain scores.

Differential Diagnosis

The differential diagnosis for chronic shoulder pain includes several etiologies:

Impingement

• External impingement or subacromial impingement syndrome
• Subcoracoid impingement
• Calcific tendonitis
• Internal (including SLAP lesions, GIRD, Little League shoulder, posterior labral tears)

Rotator Cuff Pathology 

• Partial-thickness versus full-thickness tears
• Rotator cuff arthropathy

Degenerative

• Advanced degenerative joint disease, often associated with rotator cuff arthropathy
• Glenohumeral arthritis
• Adhesive capsulitis
• Avascular necrosis 
• Scapulothoracic crepitus

Proximal Biceps

• Subluxation–often seen in association with subscapularis injuries
• Tendonitis and tendinopathy

Acromioclavicular Joint Conditions

• Acromioclavicular separation
• Distal clavicle osteolysis
• Acromioclavicular arthritis

Instability 

• Unidirectional instability–seen in association with an inciting event/dislocation (anterior, posterior, inferior)
• Multidirectional instability
• Associated labral injuries or pathology

Neurovascular Conditions

• Suprascapular neuropathy, which can be associated with a  paralabral cyst at the spinoglenoid notch
• Scapular winging–medial or lateral
• Brachial neuritis
• Thoracic outlet syndrome 
• Quadrilateral space syndrome

Other Conditions

• Scapulothoracic dyskinesia
• Os acromiale
• Muscle ruptures (pectoralis major, deltoid, latissimus dorsi)
• Fracture, including acute injury or pain resulting from long-standing deformity, malunion, or nonunion

Prognosis

Patients with persistent, debilitating symptoms in the setting of known proximal biceps tendon pathology are good surgical candidates for either a tenotomy or tenodesis procedure. The literature demonstrates high levels of patient satisfaction, patient-reported pain, and overall outcome scores at long-term follow-up. Results from a 2017 study of more than 100 patients who were 1 year after arthroscopic surgical procedures with concomitant biceps tenotomy revealed that more than 90% were satisfied or very satisfied with their outcomes. In addition, 95% stated that they would have the same surgical procedure again.[31] Similar positive results were demonstrated in studies following patients who underwent biceps tenodesis at long-term follow-up. In addition, most reports found no appreciable difference between patients who underwent tenotomy and those who underwent tenodesis in recovery of elbow flexion and forearm supination strength.[32]

Complications

The approximate rates of the most common postoperative surgical complications relative to each procedure:

Biceps Tenotomy

• Cosmetic (Popeye) deformity: 10% to 70%
• Muscle spasm/cramping: 15% to 25%
• Biceps pain: 10% to 20% [2][32]

Biceps Tenodesis

• Groove pain: 0% to 25% 
• Cosmetic (Popeye) deformity: 10% to 15%
• Muscle spasm/cramping: 5% to 10%
• Biceps pain: 5% to 10%
• Humeral shaft fracture

  • Results from recent case reports describe spiral humeral fractures after subpectoral biceps tenodesis performed with an 8-mm interference screw, raising concern for increased fracture susceptibility when the humerus is subjected to torsional stress.[33][34]

Postoperative and Rehabilitation Care

For isolated biceps procedures, typical postoperative protocols are as follows:

Biceps Tenotomy

Rehab phases:

• Sling use for 1 to 2 weeks
• Active range of motion begins at 2 to 4 weeks postoperatively; sling discontinued
• Strengthening begins at 4 to 6 weeks postoperatively

Return to work/activity:

• Patients typically can resume light work by 3 to 4 weeks postoperatively
• Depending on occupational demands, return to full duty ranges from 1 to 3 months after surgery
• Most patients return to unrestricted activities at 3 to 4 months postoperatively 

Biceps Tenodesis

Rehab phases:

• Sling use for 3 to 4 weeks
• The initial period includes passive elbow range of motion and grip strengthening
• Avoid active elbow flexion and forearm supination until the 6-week mark
• The goal is to achieve full active and passive shoulder ROM by 6 weeks

Return to work:

• Patients typically can resume light work by 3 to 4 weeks postoperatively
• Depending on occupational demands, return to full duty ranges from 2 months to 4 months from surgery
• Most patients return to unrestricted activities at 3 to 4 months postoperatively

Consultations

Most patients with LHB tendinitis can be treated nonoperatively. Referral should be considered in the setting of persistent pain or symptoms despite 6 to 8 weeks of nonoperative treatment. In addition, referral for an appropriate physical therapy program should focus on correcting any existing muscular imbalances around the shoulder girdle, including scapular dyskinesia.

In young athletes, early referral to a sports medicine clinician experienced in treating these types of shoulder pathologies should be considered. Again, because most biceps-related shoulder pathologies can be treated nonoperatively, referral to an orthopedic surgeon for surgical treatment should be considered in any of the following scenarios:

• Persistent/worsening symptoms despite physical therapy, nonsteroidal anti-inflammatory drugs, activity modification, or injections
• Diagnostic imaging confirming evidence of tendon subluxation and/or dislocation
• In the setting of either postoperative Popeye deformity, failed biceps tenodesis techniques, or spontaneous rupture, referral to a surgeon with experience in correcting the deformity should be considered

Deterrence and Patient Education

Patients should be educated about the possible etiologies and concomitant shoulder pathologies associated with proximal biceps pathologies. A point of emphasis should be given to including any LHB tendon pathology that may be seen in association with other known shoulder pathologies. For example, a patient should be educated not only on the rotator cuff injury itself, but also on the potential for coexisting biceps tendon injury. Discussion, especially with older patient populations, should include the possibility that the planned concomitant procedure (ie, the tenotomy or tenodesis procedure) may not be performed. By doing this, the patient’s postoperative expectations can be adequately managed before performing surgery.

Enhancing Healthcare Team Outcomes

Long head of the biceps (LHB) tendon pathologies spans a clinical spectrum, from acute tendinitis to chronic degenerative tendinopathy and spontaneous tendon rupture. In athletic populations, the clinician must coordinate and work in tandem with his or her physical therapists to ensure that the athlete's potential is realized and that coexisting shoulder girdle risk factors are addressed appropriately. In throwers, it is critical to recognize that poor trunk control, scapular dyskinesia, shoulder girdle atrophy, and muscular imbalances all can contribute to the proximal biceps tendinitis. Thus, the comprehensive management of these injuries often involves a team of head coaches and athletic trainers in athletic populations, as well as general clinicians, geriatricians, sports medicine primary care clinicians, physiatrists, orthopedic sports medicine specialists, and physical therapists.

Failed nonoperative management is an indication for proceeding with surgical treatment. Other indications for surgery include:

• Partial-thickness tears of the LHB tendon (> 25% to 50%)
• Medial LHB tendon subluxation/dislocation
• LHB tendon subluxation/dislocation with associated bicipital groove soft tissue stabilizer injury; also may or may not include injuries to the subscapularis muscle/tendon

The two most common surgical techniques are biceps tenodesis and biceps tenotomy. The literature demonstrates equivalent outcomes across procedures, and both techniques yield high rates of patient satisfaction and clinical outcomes at long-term follow-up.  Orthopedic and rehabilitation nurses educate patients, monitor progress, and report changes to the interprofessional team. Physical therapists must work closely with postoperative patients at the direction of the orthopedist. 

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Disclosure: Matthew Varacallo declares no relevant financial relationships with ineligible companies.

Disclosure: Scott Mair declares no relevant financial relationships with ineligible companies.