Bicipital Tendinitis: And Physiotherapy Exercise

Bicipital Tendinitis 

Biceps tendinitis is inflammation of the tendon around the long head of the biceps muscle.

Biceps tendinitis is a common injury that occurs when the muscles and connective tissues of the arm become inflamed and swollen due to overuse. The biceps muscle is located in the upper arm, and it helps with both flexion and rotation of the shoulder joint. The tendons that attach the biceps muscle to the bones of the shoulder are also susceptible to injury, which can lead to biceps tendinitis.

Overview:

Biceps tendinosis is caused by degeneration of the tendon from athletics requiring overhead motion or from the normal aging process.

Inflam-mation of the biceps tendon in the bicipital groove, which is known as primary biceps tendinitis, occurs in 5 percent of patients with biceps tendinitis.

Biceps tendinitis and tendinosis are commonly accompanied by rotator cuff tears or SLAP (superior labrum anterior to posterior) lesions. Patients with biceps tendinitis or tendinosis usually complain of a deep, throbbing ache in the anterior shoulder. Repetitive overhead motion of the arm initiates or exacerbates the symptoms. 

The most common isolated clinical finding in biceps tendinitis is bicipital groove point tenderness with the arm in 10 degrees of internal rotation. Local anesthetic injections into the biceps tendon sheath may be therapeutic and diagnostic. Ultrasonography is preferred for visualizing the overall tendon, whereas magnetic resonance imaging or computed tomography arthrography is preferred for visualizing the intraarticular tendon and related pathology. 

Conservative management of biceps tendinitis consists of rest, ice, oral analgesics, physical therapy, or corticosteroid injections into the biceps tendon sheath. Surgery should be considered if conservative measures fail after three months, or if there is severe damage to the biceps tendon.

Anatomy and Physiology:

The long head of the biceps tendon rises from the supraglenoid tubercle and the superior glenoid labrum. 

The proximal portion of the long head of the biceps tendon is extrasynovial but intra-articular.
5 The tendon travels obliquely inside the shoulder joint, across the humeral head anteriorly, and exits the joint within the bicipital groove of the humeral head beneath the transverse humeral ligament.
 

The bicipital groove is defined by the greater tuberosity (lateral) and the lesser tuberosity (medial). The biceps tendon is contained in the rotator interval, a triangular area between the subscapularis and supraspinatus tendons at the shoulder (Figure 1). The rotator interval is responsible for keeping the biceps tendon in its correct location.6–8 Because the rotator interval is usually indistinguishable from the rotator cuff and capsule, lesions of the biceps tendon are usually accompanied by lesions of the rotator cuff.

SLAP lesions are often present in patients with biceps tendinitis and tendinosis. The anterosuperior labrum and superior labrum are more likely to tear than the inferior portion of the labrum because they are not attached as tightly to the glenoid.9–13 Additionally, certain conditions that affect the glenohumeral joint may also involve the biceps tendon because it is intra-articular. These may include rheumatologic (e.g., rheumatoid arthritis, lupus), infectious, or other types of reactive or inflammatory conditions.

Symptoms:

Bicipital Tendinitis 

Patients with biceps tendinitis often complain of a deep, throbbing ache in the anterior shoulder. The pain is usually localized to the bicipital groove and may radiate toward the insertion of the deltoid muscle, or down to the hand in a radial distribution.

This makes it difficult to distinguish from pain that is secondary to impingement or tendinitis of the rotator cuff, or cervical disk disease. Pain from biceps tendinitis usually worsens at night, especially if the patient sleeps on the affected shoulder.

Repetitive overhead arm motion, pulling, or lifting may also initiate or exacerbate the pain.9 The pain is most noticeable in the follow-through of a throwing motion.3 Instability of the tendon may present as a palpable or audible snap when range of motion of the arm is tested.

Rupture of the biceps tendon is one of the most common musculotendinous tears. If the biceps has ruptured, patients will describe an audible, painful popping, followed by relief of symptoms. The anterior shoulder may be bruised, with a bulge visible above the elbow as the muscle retracts distally from the rupture point. Risk factors of biceps rupture include a history of rotator cuff tear, recurrent tendinitis, contralateral biceps tendon rupture, rheumatoid arthritis, age older than 40 years, and poor conditioning.9 If a patient has a feeling of popping, catching, or locking in the shoulder, a SLAP lesion may be present. This usually occurs after trauma, such as a direct blow to the shoulder, a fall on an outstretched arm, or repetitive overhead motion in athletes.

The most common finding of biceps tendon injury is bicipital groove point tenderness.


PHYSICAL EXAMINATION:

Many provocative tests (i.e., Yergason, Neer, Hawkins, and Speed tests) have been developed to isolate pathology of the biceps tendonhowever, because these tests create impingement underneath the coracoacromial arch, it is difficult to rule out concomitant rotator cuff lesions.

The Yergason test requires the patient to place the arm at his or her side with the elbow flexed at 90 degrees, and supinate against resistance18 (Figure 2). The test is considered positive if pain is referred to the bicipital groove.

The Neer test involves internal rotation of the arm while in the forward flexed position16. If the patient experiences pain, it is a positive sign of impingement syndrome.

During the Hawkins test, the patient flexes the elbow to 90 degrees while the physician elevates the patient's shoulder to 90 degrees and places the forearm in a neutral position19 (Figure 4). With the arm supported, the humerus is rotated internally. The test is positive if bicipital groove pain is present.


Speed test, the patient tries to flex the shoulder against resistance with the elbow extended and the forearm supinated9,20 (Figure 5). A positive test is pain radiating to the bicipital groove. If any of these tests is positive, it indicates that impingement is present, which can lead to biceps tendinitis or tendinosis.

Advantages and Disadvantages of Radiologic Imaging Studies in the Evaluation of Biceps Tendinitis.

IMAGING STUDY : 

Arthrography (used with MRI or CT to visualize the joint capsule and glenoid labrum)

ADVANTAGES

CT arthrography shows biceps tendon subluxations, ruptures, dislocations, and SLAP lesion
MRI arthrography is preferable for diagnosing biceps lesions and SLAP lesions14 because the agreement between MRI and arthroscopy for biceps lesions is only 37 percent and 60 percent for rotator cuff lesions

DISADVANTAGES

Invasive
Filling of the biceps tendon sheath is unreliable
Sharp images of the tendon may be lost

Ionizing radiation
Bicipital groove view radiography

ADVANTAGES

Shows the width and medial wall angle of the bicipital groove, spurs in the groove, and supertubercular bone spur or ridge
Inexpensive

DISADVANTAGES

Does not show possible intra-articular disorders of the labrum (soft tissue injuries)

MRI

ADVANTAGES

Excellent evaluation of the superior labral complex and biceps tendon

DISADVANTAGES

Partial tears of the biceps tendon are more difficult to detect than complete ruptures
Expensive
Poorly 

Treatment :


CONSERVATIVE:

Biceps tendinitis or tendinosis may respond to analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs).

Physiotherapy Treatment:

Bicipital Tendinitis And Exercise

Ice, rest from overhead activity, or physical therapy. Rehabilitation of an athlete's shoulder involves four phases:

Rest; stretching exercises of the scapula, rotator cuff, and posterior capsule; 

The goal of stretching is to regain a balanced range of motion without stiffness or pain in any position.

Taping Over Biceps Give Great Relief From Pain And Allow Smooth Movement.

Tapping in Bicipital Tendinitis

Strengthening and a progressively difficult throwing program.
The patient may begin exercises after the shoulder is pain-free.

Strengthening Exercise Of Biceps Muscle