A Patient's Guide to Biceps Tendonitis
Introduction
Biceps tendonitis, also called bicipital
tendonitis, is inflammation in the main tendon
that attaches the top of the biceps muscle to the
shoulder. The most common cause is overuse from
certain types of work or sports activities. Biceps
tendonitis may develop gradually from the effects of
wear and tear, or it can happen suddenly from a direct
injury. The tendon may also become inflamed in
response to other problems in the shoulder, such as
rotator cuff tears, impingement, or instability
(described below).
This guide will help you understand
- what parts of the shoulder are affected
- the causes of biceps tendonitis
- ways to treat this problem
Anatomy
What parts of the shoulder are affected?
The biceps muscle goes from the shoulder to the
elbow on the front of the upper arm. Two separate
tendons (tendons attach muscles to bones)
connect the upper part of the biceps muscle to the
shoulder. The upper
two tendons of the biceps are called the
proximal biceps tendons, because they are
closer to the top of the arm.
The main proximal tendon is the long head of the
biceps. It connects the biceps muscle to the top
of the shoulder socket, the glenoid. It also
blends with the cartilage rim around the glenoid, the
labrum.
The labrum is a rim of soft tissue that turns the flat
surface of the glenoid into a deeper socket. This
arrangement improves the fit of the ball that fits in
the socket, the humeral head.
Beginning at the top of the glenoid, the tendon of
the long head of the biceps runs in front of the
humeral head. The tendon passes within the
bicipital groove of the humerus and is held in
place by the transverse humeral ligament. This
arrangement keeps the humeral head from sliding too
far up or forward within the glenoid.
The short head of the biceps connects on the
coracoid
process of the scapula (shoulder
blade). The coracoid process is a small bony knob just
in from the front of the shoulder. The lower biceps
tendon is called the distal biceps tendon. The
word distal means the tendon is further down
the arm. The lower part of the biceps muscle connects
to the elbow by this tendon. The muscles forming the
short and long heads of the biceps stay separate until
just above the elbow, where they unite and connect to
the distal biceps tendon.
Tendons
are made up of strands of a material called
collagen. The collagen strands are lined up in
bundles next to each other. Because the collagen
strands in tendons are lined up, tendons have high
tensile strength. This means they can withstand
high forces that pull on both ends of the tendon. When
muscles work, they pull on one end of the tendon. The
other end of the tendon pulls on the bone, causing the
bone to move.
Contracting the biceps
muscle can bend the elbow upward. The biceps can
also help flex the shoulder, lifting the arm up, a
movement called flexion. And the muscle can
rotate, or twist, the forearm in a way that points the
palm of the hand up. This movement is called
supination, which positions the hand as if you
were holding a tray.
Related Document: A
Patient's Guide to Shoulder Anatomy
Causes
Why is my biceps tendon inflamed?
Continuous or repetitive shoulder actions can cause
overuse of the biceps tendon. Damaged cells within the
tendon don't have time to recuperate. The cells are
unable to repair themselves, leading to tendonitis.
This is common in sport or work activities that
require frequent and repeated use of the arm,
especially when the arm motions are performed
overhead. Athletes who throw, swim, or swing a racquet
or club are at greatest risk.
Years of shoulder wear and tear can cause the
biceps tendon to become inflamed. Examination of the
tissues in these cases commonly shows signs of
degeneration. Degeneration in a tendon causes a
loss of the normal arrangement of the collagen fibers
that join together to form the tendon. Some of the
individual strands of the tendon become jumbled due to
the degeneration, other fibers break, and the tendon
loses strength. When this happens in the biceps
tendon, inflammation, or even a rupture of the biceps
tendon, may occur.
Related Document: A
Patient's Guide to Rupture of the Biceps Tendon
Biceps tendonitis can happen from a direct injury,
such as a fall onto the top of the shoulder. A torn
transverse humeral ligament can also lead to biceps
tendonitis. (As mentioned earlier, the transverse
humeral ligament holds the biceps tendon within the
bicipital groove near the top of the humerus.) If this
ligament is torn, the biceps tendon is free to jump or
slip out of the groove, irritating and eventually
inflaming the biceps tendon.
Biceps tendonitis sometimes occurs in response to
other shoulder problems, including
- rotator cuff tears
- shoulder impingement
- shoulder instability
Rotator Cuff
Tears
Aging adults with rotator
cuff tears also commonly end up with biceps
tendonitis. When the rotator cuff is torn, the humeral
head is free to move too far up and forward in the
shoulder socket and can impact the biceps tendon. The
damage may begin to weaken the biceps tendon and cause
it to become inflamed.
Related Document: A
Patient's Guide to Rotator Cuff
Tears Shoulder Impingement
In shoulder impingement, the soft tissues
between the humeral head and the top of the shoulder
blade (acromion) get pinched or squeezed with
certain arm movements.
Related Document: A
Patient's Guide to Shoulder
Impingement Shoulder Instability
Conditions that allow too much movement of the ball
within the socket create shoulder instability.
When extreme shoulder motions are frequently repeated,
such as with throwing or swimming, the soft tissues
supporting the ball and socket can eventually get
stretched out.
Related Document: A
Patient's Guide to Shoulder Instability
The labrum (the cartilage rim that deepens the
glenoid, or shoulder socket) may begin to pull away
from its attachment to the glenoid. A shoulder
dislocation can also cause the labrum to tear. When
the labrum
is torn, the humeral head may begin to slip up and
forward within the socket. The added movement of the
ball within the socket (instability) can cause damage
to the nearby biceps tendon, leading to secondary
biceps tendonitis.
Related Document: A
Patient's Guide to Labral Tears
Symptoms
What does biceps tendonitis feel like?
Patients generally report the feeling of a deep
ache directly in the front and top of the shoulder.
The ache may spread down into the main part of the
biceps muscle. Pain is usually made worse with
overhead activities. Resting the shoulder generally
eases pain.
The arm may feel weak with attempts to bend the
elbow or when twisting the forearm into supination
(palm up). A catching or slipping sensation felt near
the top of the biceps muscle may suggest a tear of the
transverse humeral ligament.
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Diagnosis
How can my doctor be sure I have biceps
tendonitis?
Your doctor will first take a detailed medical
history. You will need to answer questions about your
shoulder, if you feel pain or weakness, and how this
is affecting your regular activities. You'll also be
asked about past shoulder pain or injuries.
The physical exam is often most helpful in
diagnosing biceps tendonitis. Your doctor may position
your arm to see which movements are painful or weak.
Available arm motion is checked. And by feeling the
biceps tendon, the doctor can tell if the tendon is
tender.
Special tests are done to see if nearby structures
are causing problems, such as a tear in the labrum or
in the transverse humeral ligament. The doctor checks
the shoulder for impingement, instability, or rotator
cuff problems.
X-rays are generally not needed right away. They
may be ordered if the shoulder hasn't gotten better
with treatment. An X-ray can show if there are bone
spurs or calcium deposits near the tendon. X-rays can
also show if there are other problems, such as a
fracture. Plain X-rays do not show soft tissues like
tendons and will not show a biceps tendonitis.
When the shoulder isn't responding to treatment,
magnetic resonance imaging (MRI) scan may also
be ordered. An MRI is a special imaging test that uses
magnetic waves to create pictures of the shoulder in
slices. This test can tell if there are problems in
the rotator cuff or labrum.
Arthroscopy is an invasive way to evaluate
shoulder pain that isn't going away. It is not used to
first evaluate biceps tendonitis. It may be used for
ongoing shoulder problems that haven't been found in
an X-ray or MRI scan. The surgeon uses an
arthroscope to see inside the joint. The
arthroscope is a thin instrument that has a tiny
camera on the end. It can show if there are problems
with the rotator cuff, the labrum, or the portion of
the biceps tendon that is inside the shoulder
joint.
Treatment
What treatment options are available?
Nonsurgical Treatment
Whenever possible, doctors treat biceps tendonitis
without surgery. Treatment usually begins by resting
the sore shoulder. The sport or activity that led to
the problem is avoided. Resting the shoulder relieves
pain and calms inflammation.
Anti-inflammatory medicine may be prescribed to
ease pain and to help patients return to normal
activity. These medications include common
over-the-counter drugs such as ibuprofen.
Doctors may have their patients work with a
physical or occupational therapist. Therapists apply
treatments to reduce pain and inflammation. When
present, conditions causing the biceps tendonitis are
also addressed. For example, shoulder impingement may
require specialized hands-on joint mobilization, along
with strengthening of the rotator cuff and shoulder
blade muscles. Treating the main cause will normally
get rid of the biceps tendonitis. When needed,
therapists also evaluate the way you do your work or
sport activities to reduce problems of overuse.
In rare instances, an injection of cortisone
may be used to try to control pain. Cortisone is a
very powerful steroid. However, cortisone is used very
sparingly because it can weaken the biceps tendon, and
possibly cause it to rupture.
Surgery
Patients who are improving with conservative
treatments do not typically require surgery. Surgery
may be recommended if the problem doesn't go away or
when there are other shoulder problems present.
Acromioplasty
The most common surgery for bicipital tendonitis is
acromioplasty, especially when the underlying
problem is shoulder impingement. This procedure
involves removing the front portion of the acromion,
the bony ledge formed where the scapula meets the top
of the shoulder joint. By removing a small portion of
the acromion, more space is created between the
acromion and the humeral head. This takes pressure off
the soft tissues in between, including the biceps
tendon.
Acromioplasty is usually done through a two-inch
incision in the skin over the shoulder joint. In some
cases, the surgery can be done using an arthroscope.
Working through the incision, the surgeon locates
the deltoid muscle on the outer part of the
shoulder. Splitting the front section of this muscle
gives the surgeon a better view of the acromion. Some
surgeons also detach the deltoid muscle where it
connects on the front of the acromion.
The bursa sac that lies just under the
acromion is removed. Next, a surgical tool is used to
cut a small portion off the front of the acromion. The
ligament arcing from the acromion to the corocoid
process (the coracoacromial ligament) may also
be removed.
The surgeon shaves the undersurface of the acromion
to remove any bone spurs. A file is used to smooth the
edge of the acromion. Next, a series of small holes is
drilled into the remaining acromion. These holes are
used to reattach
the deltoid muscle to the acromion.
The surgeon inspects the rotator cuff muscle to see
if any tears are present. Then the entire area is
irrigated to wash away small particles of bone.
Finally, the free end of the deltoid muscle is sutured
back to the ridge of the acromion using the drill
holes made earlier.
If the biceps tendon is severely degenerated, the
surgeon may perform biceps tenodesis (described next).
The surgeon completes the procedure by closing the
incision with sutures.
Biceps Tenodesis
Biceps tenodesis is a method of reattaching
the top end of the biceps tendon to a new location.
Studies show that the long-term results of this form
of surgery are not satisfactory for patients with
biceps tendonitis. However, tenodesis may be needed
when the biceps tendon is severely degenerated or when
shoulder reconstruction for other problems is needed.
A common way to do this surgery is called the
keyhole technique. The keyhole describes
the shape of a small hole made by the surgeon in the
humerus. The end of the tendon is slid into the top of
the keyhole and pulled down to anchor it in place.
The surgeon begins by making an incision
on the front of the shoulder, just above the
axilla (armpit). The overlying muscles are
separated so the surgeon can locate the top of the
biceps tendon. The end of the biceps tendon is removed
from its attachment at the top of the glenoid. The
tendon is prepared by cutting away frayed and
degenerated tissue.
The transverse
humeral ligament is split, exposing the bicipital
groove. An incision is made along the floor of the
bicipital groove. The bleeding from the incision gets
scar tissue to form that will help anchor the repaired
tendon in place.
A burr is used to form a keyhole-shaped
cavity within the bicipital groove. The top of the
cavity is round. The bottom is the slot of the
keyhole. It is made the same width as the biceps
tendon.
The surgeon rolls the top end of the biceps
tendon into a ball. Sutures are used to form and
hold the ball. The elbow is bent, taking tension off
the biceps muscle and tendon. The surgeon pushes the
tendon ball into the top part of the keyhole. As the
elbow is gradually straightened, the ball is pulled
firmly into the narrow slot in the lower end of the
keyhole.
Rehabilitation
What should I expect after treatment?
Nonsurgical Rehabilitation
You will need to avoid heavy arm activity for three
to four weeks. As the pain resolves, you should be
safe to begin doing more normal activities.
Your doctor may prescribe a carefully progressed
rehabilitation program under the supervision of a
physical or occupational therapist. This could involve
four to six weeks of therapy. At first, treatments are
used to calm inflammation and to improve shoulder
range of motion. As symptoms ease, specific exercises
are used to strengthen the biceps muscle, as well as
the rotator cuff and scapular muscles. Overhead
athletes are shown ways to safely resume their
sport.
After Surgery
Some surgeons prefer to have their patients start a
gentle range-of-motion program soon after surgery.
When you start therapy, your first few therapy
sessions may involve ice and electrical stimulation
treatments to help control pain and swelling from the
surgery. Your therapist may also use massage and other
types of hands-on treatments to ease muscle spasm and
pain.
You will gradually start exercises to improve
movement in the forearm, elbow, and shoulder. You need
to be careful to avoid doing too much, too
quickly.
Heavier exercises for the biceps muscle are avoided
for two to four weeks after surgery. Your therapist
may begin with light isometric strengthening
exercises. These exercises work the biceps muscle
without straining the healing tendon.
After two to four weeks, you start doing more
active strengthening. As you progress, your therapist
will teach you exercises to strengthen and stabilize
the muscles and joints of the elbow and shoulder.
Other exercises will work your arm in ways that are
similar to your work tasks and sport activities. Your
therapist will help you find ways to do your tasks
that don't put too much stress on your shoulder.
You may require therapy for six to eight weeks. It
generally takes three to four months, however, to
safely begin doing forceful biceps activity after
surgery. Before your therapy sessions end, your
therapist will teach you a number of ways to avoid
future problems. |