Long biceps tendonitis
Image showing inflammation of the biceps tendon

Definition

Bicipital or biceps tendonitis refers to the inflammation of the tendon that connects the upper biceps with the shoulder.

Anatomy of a healthy shoulder showing the biceps tendon relative to the glenoid, rotator cuff and bursa (purple)

Pathology

Anatomical considerations: The biceps muscle is used to bend (flex) the elbow, rotate the arm (supination) and is important to stabilise the shoulder joint. The proximal end of the biceps muscle is connected to the shoulder by the short head inserting to the coracoid process and the long head, which attaches the biceps to the supraglenoid tubercle and the glenoid labrum. The distal tendon at the elbow is attached to the proximal end of the radius. Tendonitis of the long biceps tendon is caused by a prolonged inflammation of the collagenous tissue forming the tendon. As a result of the inflammation the tendon degenerates and becomes reddish, swollen, weak and more prone to a tear. With its complete rupture, the biceps muscle is deformed and on contraction it produces a bulging swelling above the elbow joint, which is often referred to as “Popeye arm”. This pathology is often found in concomitance with other conditions of the shoulder such as arthritis, instability and impingement, tear of the glenoid labrum and other inflammatory conditions of the joint.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Heavy weight lifting can cause biceps tendonitis

Causes

Inflammation of the long biceps tendon is mostly due to prolonged overuse by repetitive overhead activities. It can also result from a sudden injury caused by an excessive force applied to the biceps tendons whilst lifting or carrying a heavy weight with the upper extremity. Additional factors can contribute to long biceps tendonitis:

Tear of the rotator cuff

Shoulder instability

Joint stiffness especially of the elbow

Lack of, or excessive training

Inadequate warm up

Weakness of the muscles

Tightness of the biceps

Repetitive challenging sport is a risk factor for biceps tendonitis

Risk factors

Men between 20 and 40 years are more often affected by this pathology. Those individuals regularly active in golfing, swimming, tennis, baseball, basketball as well as those involved in heavy weight lifting are at greater risk to develop long biceps tendonitis.

Pain is the common symptom of a biceps tendonitis

Symptoms

The main symptom of long biceps tendonitis is pain in the front of the shoulder and upper arm, which is exacerbated during overhead activity and weight lifting. Frequent is a sensation of pain whilst extending the arm. Occasionally snapping or catching noises can be heard during moving the shoulder.

Palpation of the shoulder area and arm is part of the medical examination

Diagnosis

A detailed medical history is recorded to assess past injuries of the shoulder, pre-existing chronic inflammatory conditions, predisposing physical activities and a description of ongoing symptoms. Medical examination includes:

Palpation of the shoulder

Identification of movement restriction

Testing for reduced muscular strength of the biceps

Shoulder instability

X-rays are only performed to exclude other pathologies of the shoulder joint. Ultrasound and MRI are not routinely recommended but are also employed to better visualise the integrity of the biceps tendon

Treatment

Oral therapy with NSAIDs (non-steroidal antiinflammatory drugs) is recommended to reduce inflammation, pain and swelling of biceps tendonitis

Nonoperative treatment

Conservative treatment is the most common approach to long biceps tendonitis. Rest from those activities causing stress to the tendon and daily applications of ice pads are recommended. Administration of NSAIDs is efficacious to reduce inflammation, swelling and pain. Injection of steroids within the tendon can be done but presents the risk of further weakening the tendon, possibly leading to its rupture.

Normal (L) and frying (R) biceps tendon seen during arthroscopic surgery

Surgical treatment

Different surgical methods are available to treat long biceps tendonitis. The outcome of surgery is usually satisfactory, however in some cases those athletes involved in high demanding sports may need to reduce their activities.

Arthroscopic surgery This surgical approach is performed to determine the status of the tendon and of other components of the shoulder. A debridement can be performed to smoothen the tendon by removing the irregular fibres that have been damaged.

Biceps tenodesis

Biceps Tenodesis Arthroscopic scissors are inserted via a small incision to severe the long head biceps tendon. Once exposed, the tendon is cut and then fixed to the humerus head using a screw.

Biceps tenotomy

Biceps Tenotomy Arthroscopic scissors are inserted via a small incision to the shoulder to cut the long head biceps tendon without reconnection to the bone. Despite being detached the functional impairment of the shoulder is minimal. Following tenotomy, the function of the biceps muscle is maintained by the short head biceps tendon.

Physiotherapy can begin once the inflammation has subsided

Rehabilitation

Most patients with long biceps tendonitis recover well following a rehabilitation program and are able to return to normal activities after a few weeks or, in more severe cases, after a few months. After surgery, the use of a sling is recommended for up to three weeks to allow for the repair of the tendon. The sling is always kept on during the night and while walking but it can be removed for restricted daily activities (showering, changing of clothes). Following this period of immobilisation, an intensive rehabilitative therapy can begin under the guidance of a physiotherapist. This focuses on reacquiring flexibility of the shoulder and elbow as well as strengthening the biceps muscle. Therapy includes massage, stretching exercises and preparing the patient to a gradual return to strenuous physical work.

Stretching prior to workout is advised to prevent biceps tendonitis

Prevention

A guided education on physical activities is crucial to prevent the recurrence of long biceps tendonitis. Regular stretching exercise, warm up and avoidance of heavy weights are key elements for maintaining a strong biceps tendon and muscle. Particular care should be taken in the transition from rehabilitation therapy to sport activity.