Biceps Tenosynovitis

Aka: Biceps Tenosynovitis, Bicipital Tenosynovitis, Biceps Tendinopathy, Bicipital Tendinitis, Biceps Tendinitis, Biceps Tendinosis

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II. Types

  1. Primary Biceps Tendinitis (5% of cases)
    1. Inflammation within bicipital groove
    2. Long head of biceps tendon and sheath
  2. Secondary Biceps Tendinitis (95% of cases)
    1. Rotator Cuff Tear or
    2. Superior Labrum Anterior to Posterior Tear (SLAP Lesion)

III. Risk factors

  1. Biceps tendon impingement primary causes (impingement under coracoacromial arch)
    1. Acromion bone spur
    2. Unfused acromial apophysis
    3. Coracoacromial ligament thickening
  2. Biceps tendon impingement secondary causes
    1. Scapular instability
    2. Shoulder ligamentous instability
    3. Lax anterior capsule
    4. Tight posterior capsule
    5. Labral tear
    6. Rotator Cuff Tear
    7. Osteoarthritic spurs at bicipital groove
  3. Associated activities at higher risk for acute Tendinitis or chronic overuse Tendinosis
    1. Repetitive throwing
    2. Contact Sports
    3. Swimming
    4. Gymnastics
    5. Martial arts
  4. Secondary inflammation due to Arthritis (tendon originates inside Shoulder joint)
    1. Rheumatoid Arthritis
    2. System lupus erythematosus
    3. Reactive Arthritis
    4. Septic Arthritis

IV. Background: Anatomy

  1. Images
    1. ShoulderAnteriorBiceps.jpg
  2. Long head of biceps
    1. Originates at supra-glenoid tubercle (anterior superior aspect adjacent to glenoid fossa)
    2. Travels laterally through Shoulder joint in front of Humerus
    3. Descends under the transverse humeral ligament and into the bicipital groove
      1. Transverse humeral ligament acts as a pulley, reorienting the tendon inferiorly
      2. Landmarks: Groove lies between greater tuberosity (lateral) and less tuberosity (medial)

V. Symptoms

  1. Anterior Shoulder, deep throbbing ache
  2. Radiation along bicipital groove into hand or into deltoid tendon insertion
  3. Provocative factors
    1. Sleeping on affected Shoulder
    2. Repetitive motion (overhead activity, pulling, lifting)
    3. Worse during follow-through of throwing motion

VI. Signs

  1. Tenderness over bicipital groove
  2. Biceps Tendon Instability may cause a palpable or audible snap on range of motion testing
  3. Pain limits active and passive range of motion
  4. Maneuvers that stretch biceps elicit pain
    1. Forceful external rotation with abduction (shifts bicipital groove to a posterolateral position)
    2. Arm extension with elbow extended
  5. Yergason Test
  6. Speed's Test

VII. Differential Diagnosis

  1. Rotator Cuff Impingement or Rotator Cuff Tear
  2. Cervical Disc Disease

VIII. Precautions

  1. Bicipital Tendon Injury is commonly associated with Rotator Cuff Injury or SLAP Lesion

IX. Management

  1. Acute management (until pain resolves)
    1. Rest
    2. Moist heat
    3. Gentle range of motion
    4. NSAIDs
    5. Avoid motion that stretches biceps tendon (especially overhead motion)
    6. Sling temporarily if needed (but avoid immobility due to risk of Frozen Shoulder)
  2. Rehabilitation Exercises (start when pain free)
    1. Step 1: StretchingExercises
      1. Shoulder specific Stretching: Scapula, Rotator Cuff and Posterior Capsule
      2. Hamstrings
      3. Low Back
    2. Step 2: Strengthening Exercises
      1. Rotator cuff Muscles
      2. Scapular rotator Muscles
      3. Humeral motion Muscles (pectoralis major, latissimus dorsi, and deltoid Muscles)
    3. Step 3: Throwing program (athletes)
  3. Biceps Tendon Injection
    1. Local Corticosteroid Injection at tendon sheath under Ultrasound guidance (see Shoulder Ultrasound)
    2. Approached in-plane to linear Ultrasound probe (probe short axis to anterior Shoulder - home position)
    3. Do not inject within tendon (and avoid circumflex artery within groove)
    4. May also help differentiate rotator cuff source of pain from primary Bicipital Tendinitis
  4. Surgery is indicated for failed conservative therapy after 3 months
    1. Partial Biceps Tendon Rupture (<50%): Debridement
      1. Debridement of impinging structures
    2. Ruptured tendon and age <60, athletes or otherwise active: Biceps tenodesis
      1. Tendon anchored in the bicipital groove
    3. Ruptured tendon and age over 60 years: Biceps tenotomy
      1. Biceps tendon removed from glenohumeral joint without loss of function

X. References

  1. Churgay (2009) Am Fam Physician 80(5): 470-6 [PubMed]
  2. Kane (2019) Am Fam Physician 100(3): 147-57 [PubMed]
  3. Patton (2001) Clin Sports Med 20(3):505-29 [PubMed]

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