Proximal Biceps Tendinitis and Tendinopathy

What is Proximal Biceps Tendinitis and Tendinopathy?

The long head of the biceps, a tendon located in your upper arm, starts from a small bump near your shoulder joint and a part of your shoulder socket. More often than not, it’s situated at the back of this socket. Inside this joint, the tendon isn’t protected by a fluid-filled sac we call synovium and it inclines as it moves towards a groove in your upper arm. The long head and the short head of the biceps, another tendon, come together in the center of the upper arm, becoming muscle. The two tendons then pass over the inner part of the elbow, and attach to the bone in your forearm and to a layer of fibrous tissue. The connection to the fibrous tissue takes place via a fibrous extension of the muscles, known as the ‘bicipital aponeurosis’.

The blood supply to this tendon comes from the anterior humeral circumflex artery, a blood vessel found in your upper arm. However, two areas with less blood supply have been identified on this tendon; one on the hidden underside of the tendon in the groove and the other near where it attaches at the shoulder.

The “bicipital groove” is an important landmark – it’s a depression between two bumps on the bone, and it’s crucial for the biceps to stay in place. Soft tissues in the groove form a kind of support sling for the tendon, which consists of parts of the rotator cuff muscles (found in the shoulder), the coracohumeral ligament (a band of tissue in the shoulder) and the superior glenohumeral ligament (another band of tissue in the shoulder).

As for what the tendon does, it’s a bit of a debate how much it helps to stabilize the shoulder joint. While studies on cadavers and animals have shown that the tendon does offer some passive stability to the shoulder, it was suggested in the 1970s that its role changes based on the position of the elbow. However, following research has disputed the idea that it plays a significant role. Studies studying the biceps activity during a throwing motion in athletes showed that the biceps peak activity happened during the bending of the elbow and slowing down of the forearm, with very little shoulder activity during the early phases of throwing.

So, for most healthy people, the tendon doesn’t really help with the stability of the shoulder. Instead, the biceps muscle is responsible for the rotation of the forearm and the bending of the elbow. Additionally, the muscle provides 10% of the total power when lifting your arm sideways, specifically when your arm is turned outward.

What Causes Proximal Biceps Tendinitis and Tendinopathy?

Biceps tendonitis is a painful condition where the tissue connecting your biceps muscle to your shoulder becomes inflamed. This usually happens to the long head of the biceps (LHB) tendon which is found in the grove at the top of the upper arm bone (humerus). This condition can go from a sudden inflammation, which is a bit like a small fire happening in the tendon, to a slow degeneration or wearing down of the tendon over time.

Most of the time, biceps tendonitis is linked to other issues with the shoulder, and not just a condition on its own. Some people, however, do get biceps tendonitis by itself, but it’s not really clear why. It’s been noticed that young, fit people who play certain sports like baseball, softball or volleyball sometimes get biceps tendonitis without any obvious cause. There are also a few cases of people with certain medical conditions suddenly experiencing a biceps tendon rupture.

The more typical situation is where biceps tendonitis develops in connection with other shoulder problems. This is seen a lot, and it’s been recognized in medical studies since the early 1980s. For example, a study in 1982 found that the more severe a person’s rotator cuff condition (a group of muscles and tendons that stabilise the shoulder), the more inflamed the LHB tendon became. Other shoulder-related issues associated with biceps tendonitis include:

* Rotator cuff injuries
* Injuries to the subscapularis muscle which is part of the rotator cuff
* The LHB tendon becoming unstable or dislocating, often tied to a tear in the subscapularis muscle
* Direct injury, or injury caused by a sudden jolt to the shoulder
* Inflammatory conditions
* Internal ‘impingement’ or pinching of the shoulder, often called “Thrower’s” shoulder, which affects baseball pitchers and others who use a similar action
* Restriction in inward rotation of the shoulder (GIRD)
* Superior labrum lesions which involve a tear in the upper part of the labrum, a type of cartilage in the shoulder
* External impingement or pinching in the space below the acromion, an extension of the shoulder blade
* Arthritis in the shoulder joint.

Risk Factors and Frequency for Proximal Biceps Tendinitis and Tendinopathy

Primary tendinitis of the long head of the biceps (LHB) makes up about 5% of issues related to this muscle’s upper part. It’s less common to see isolated cases. When they do occur, they’re usually in young athletes who participate in sports like baseball, softball, volleyball, gymnastics, and swimming.

Most cases of LHB tendinitis are related to other shoulder injuries. It often happens in combination with problems in the rotator cuff (RC), shoulder impingement (EI/SIS), or injuries to the subscapularis muscle. When someone has a RC tear, most of the time (90%) they also have LHB tendinitis, and in almost half of these cases (45%), LHB instability is another issue.

Signs and Symptoms of Proximal Biceps Tendinitis and Tendinopathy

When considering patients who present with either acute or chronic shoulder pain, doctors must gather a full health history. Some common characteristics of proximal biceps tendinitis include:

• Shoulder pain that comes on gradually without any specific injury
• Pain that gets worse during overhead activities
• Pain that travels from the shoulder down the front of the arm
• Experiencing clicking or audible popping, particularly if the shoulder is unstable
• Pain when at rest or during the night
• Current or previous sports activities, especially those involving overhead motion like baseball or volleyball
• Working in a manual or physically demanding job

Additionally, doctors consider the patient’s employment history, which hand they favor, past history of shoulder or neck injury, and any relevant surgeries.

Doctors must also examine the neck and shoulder. In checking for coexisting neck conditions, doctors will observe the neck’s posture, muscle symmetry, palpable discomfort, and range of motion. Special tests like the Spurling maneuver, reflex testing, and a comprehensive exam of the nervous system and vessels may be necessary.

During the shoulder examination, clinicians check for symmetry, shoulder posture, muscle bulk, and any abnormalities in the shoulder blade. They also inspect the skin for previous surgical scars, redness, or hardening. In severe cases of biceps pathology, there could be extensive bruising, or they might display a notable “Popeye” deformity due to a complete rupture of the tendon.

To further assess, the doctor will document the patient’s range of motion, doing this on both active (self-initiated) and passive (doctor-initiated) movements. This examination is especially important for differentiating a range of shoulder conditions.

Doctors may also assess the strength of the muscles with specific tests for each muscle group in the shoulder. As part of this, they will also check for any issues with the labrum (a type of cartilage in the shoulder joint) and the shoulder blade.

Associated labral or shoulder joint problems will also be considered. Additionally, doctors will run specific physical tests to investigate the cause of pain.

Similarly, clinicians will check for possible related issues with the muscles that move the shoulder—the rotator cuff. These tests include Jobe test, drop arm test, strength testing, and several others for different muscles in the rotator cuff.

Finally, they will check for problems related to impingement, where the shoulder bones rub against the top part of the rotator cuff. This includes tests like the Neer impingement sign, Neer impingement test, and Hawkins test. They will also evaluate for internal impingement through specific tests.

Testing for Proximal Biceps Tendinitis and Tendinopathy

If you’re experiencing acute or chronic shoulder pain, your doctor will likely recommend imaging tests to determine the cause. These tests can take pictures of structures inside your body to help your doctor see what’s going on.

One such test is a radiograph. A specific type of radiograph, known as a true anteroposterior (AP) image of the glenohumeral joint (also called the “Grashey” view), may be recommended. This image is typically taken with you, the patient, positioned at an angle of between 30 and 45 degrees. It can be used to calculate the space between your acromion (a bony projection on your shoulder blade) and the head of your humerus (the upper arm bone). The normal space is between 7 and 14 mm, and it may be smaller than normal in cases of advanced degenerative arthritis and RCA. Other views of the shoulder, such as a lateral (or “scapular Y”) view and an axillary view, are also standard.

Routine radiographs are typically recommended. However, in many cases of LHB tendinitis, a condition that causes inflammation in a tendon in your shoulder, these images might appear normal.

Ultrasound is another imaging tool. This test uses sound waves to create images of the inside of your body. While the quality of ultrasound images can vary depending on the person performing the test, it’s often a quick, low-cost way to diagnose LHB tendon conditions. Signs of these conditions on an ultrasound might include a thickened tendon, enlargement of the sheath that surrounds the tendon, and fluid around the tendon. The ability to evaluate the shoulder while you move it can make ultrasound more accurate for detecting subtle instability. Depending on the study, ultrasound has shown to be 50% to 96% sensitive (meaning it correctly identifies people with the condition) and 98% to 100% specific (meaning it correctly identifies people without the condition) in detecting LHB pathology when compared to magnetic resonance arthrography (MRA), a more advanced imaging method.

Another imaging technique used for shoulder pain is an MRI, which can provide detailed images of your shoulder, including the LHB tendon and any fluid build-up or swelling that could suggest a problem. The MRI can be particularly beneficial in identifying other types of shoulder conditions. However, there is sometimes little agreement between MRI findings, surgery findings, and the microscopic characteristics of biceps tendinopathy.

An MRI can also evaluate the position of the LHB tendon in the bicipital groove (a groove in your upper arm bone). If the tendon isn’t in the groove, that could suggest that it’s partially or completely out of place. This often comes alongside subscapularis pathology, a condition affecting another tendon in your shoulder. MRI can also look at other conditions affecting your shoulder and the integrity of your rotator cuff, which is a group of muscles and tendons that stabilize your shoulder.

Lastly, MR arthrography, which involves injecting a contrast dye before the MRI, is highly sensitive, but only moderately specific for LHB tendon pathology. While a standard MRI can detect fluid surrounding the LHB tendon, the use of contrast can limit the test’s ability to specifically identify this condition.

Each of these imaging techniques can provide valuable information about what’s causing your shoulder pain and help guide your treatment plan.

Treatment Options for Proximal Biceps Tendinitis and Tendinopathy

When dealing with long head bicep (LHB) tendon injuries, the first course of action is typically non-surgical. Essentially, this means that patients should reduce their physical activities and take a break from anything that could worsen the injury. During this period, doctors may also recommend anti-inflammatory medication to alleviate pain and reduce inflammation.

Physical therapy can also be a massive help for such injuries. The target of physical therapy is usually to work on the reasons behind the injury, such as poor trunk control, scapular dyskinesia or a lack of internal shoulder rotation, especially in athletes like baseball pitchers. Rehab programs need to focus on rebalancing the shoulder muscles and strengthening the surrounding muscles. Sometimes, stretching exercises for muscles in front of the shoulder like the small chest muscle, or pectoralis minor, are beneficial. You may also hear of therapies like dry needling, which have shown helpful results in early studies.

If the pain continues despite these interventions, doctors can use corticosteroid injections. However, the approach to using corticosteroids is debated, particularly with regards to how the injection is done and where the injection is placed. Direct injections target the tissue enclosing the tendon rather than the tendon itself to lessen potential risks like tendon rupture.

If nonoperative management doesn’t work or if the tendon is severely damaged, surgical options might be considered. For instance, a surgery called biceps tenotomy offers usually good results in alleviating the pain and requires minimal post-op rehabilitation. During this surgery, the surgeon inspects the biceps tendon and releases it if proven unstable.

Another surgical option would be biceps tenodesis which is often recommended for younger patients or those with concerns about cosmetic changes after surgery. During this procedure, the tendon is ‘tagged’ and cut off, then reattached to a new location down the arm to recreate its usual tension.

Remember, the optimal treatment depends largely on the extent of the injury and other individual factors such as age or occupation. Therefore, always consult with your doctor to formulate a tailored treatment plan.

What else can Proximal Biceps Tendinitis and Tendinopathy be?

There are many possible causes of chronic shoulder pain. Doctors use a process called differential diagnosis to rule out these potential causes and arrive at the right diagnosis. Here are some possible causes:

• Impingement, which involves pressure or rubbing against tissues in the shoulder. This could be caused by various conditions like calcific tendonitis, or issues such as SLAP lesions and little league shoulder.
• RC pathology which includes partial- or full-thickness tears and RCA.
• Degenerative causes, which include conditions like advanced degenerative joint disease often associated with RCA, glenohumeral arthritis, adhesive capsulitis, avascular necrosis, and scapulothoracic crepitus.
• Conditions related to the proximal biceps, such as subluxation which is often seen with certain types of injuries, and tendon inflammation or damage.
• AC joint conditions, including AC separation, distal clavicle osteolysis, and AC arthritis.
• Shoulder instability, which can occur in one direction (unidirectional instability, often caused by an event or dislocation), in multiple directions (multidirectional instability), or associated with labral injuries.
• Neurovascular conditions including suprascapular neuropathy which can be associated with a cyst at the spinoglenoid notch, scapular winging, brachial neuritis, thoracic outlet syndrome, and quadrilateral space syndrome.
• Other conditions such as scapulothoracic dyskinesia, os acromiale, muscle ruptures (like pectoralis major, deltoid, latissimus dorsi), and fractures caused by acute injury or pain from long-standing deformity, malunion, or nonunion.

It’s crucial for the doctor to consider all these possibilities and conduct the appropriate tests in order to correctly diagnose and treat the cause of chronic shoulder pain.

What to expect with Proximal Biceps Tendinitis and Tendinopathy

If you’re experiencing ongoing, severe symptoms due to issues with the biceps tendon at the top of your arm, you might be a good candidate for a surgical procedure called tenotomy or tenodesis. These surgeries can help to alleviate your discomfort.

Research shows that most patients who undergo these procedures report high levels of satisfaction with their results over the long term. A study in 2017 involving over 100 patients, who had surgery to fix their biceps tendon a year ago, showed that over 90% were “satisfied” or “very satisfied” with the outcome. Furthermore, 95% said they would undergo the same procedure again.

Similar positive results have also been reported by patients who underwent biceps tenodesis surgery, another procedure targeting the biceps tendon. Additionally, most studies indicate that there’s no noticeable difference in terms of recovery of arm bending and forearm twisting strength, whether the patients underwent tenotomy or tenodesis surgery.

Possible Complications When Diagnosed with Proximal Biceps Tendinitis and Tendinopathy

Here are the approximate rates of common complications following two types of surgical procedures – Biceps Tenotomy and Biceps Tenodesis.

For Biceps Tenotomy:

• A visible arm muscle bulge (“Popeye”) deformity: 10% to 70% cases
• Muscle spasms or cramping: 15% to 25% cases
• Pain in the biceps: 10% to 20% cases

For Biceps Tenodesis:

• Pain in the groove: 0% to 25% cases
• A visible arm muscle bulge (“Popeye”) deformity: 10% to 15% cases
• Muscle spasms or cramping: 5% to 10% cases
• Pain in the biceps: 5% to 10% cases
• Potential for fracture in the upper arm’s bone. Recent cases have reported spiral fractures in the upper arm after the procedure using an 8-mm interference screw. This has raised concerns about the increased risk of fracture when the upper arm bone is subjected to a twisting force.

Recovery from Proximal Biceps Tendinitis and Tendinopathy

If you’ve undergone an isolated biceps procedure, then here’s what you can typically expect for your recovery:

For a biceps tenotomy (a procedure where your bicep tendon is cut loose):

Rehabilitation Steps:

• Use of a support sling for 1 to 2 weeks
• Active range of motion exercises begin at 2 to 4 weeks after the surgery; at this point, you can stop using the sling
• Strengthening exercises commence at 4 to 6 weeks after surgery

Returning to Daily Activities:

• Light work duties can typically be resumed 3 to 4 weeks after surgery
• Depending on the demands of your job or daily activities, your full return may be possible 1 to 3 months after surgery
• You can expect to resume unrestricted activities at 3 to 4 months after the surgery

For a biceps tenodesis (a procedure where your bicep tendon is reattached to the bone):

Rehabilitation Steps:

• You should use a support sling for 3 to 4 weeks
• Initially, recovery includes passive elbow movement exercises and grip strengthening
• Your should avoid active elbow bending and turning your forearm palm-side up until you reach the 6-week mark
• Aim to achieve full, active, and passive shoulder movement by six weeks

Returning to Daily Activities:

• Light work duties can typically be resumed 3 to 4 weeks after surgery
• Depending on the demands of your job or daily activities, your full return may take 2 to 4 months after surgery
• You can expect to resume unrestricted activities at 3 to 4 months after the procedure

Preventing Proximal Biceps Tendinitis and Tendinopathy

Patients should be made aware of the different possible causes and related conditions of shoulder problems, particularly those associated with issues in the upper part of the bicep muscle. It’s important to cover any issues with the long head of the biceps (LHB) tendon that might occur alongside other known shoulder conditions. For instance, a patient should not only be informed about an injury affecting the rotator cuff (a group of muscles and tendons that provide shoulder movement and stability), but also the possibility of simultaneous injury to the biceps tendon. Especially when dealing with older patients, it should be highlighted that the planned additional procedure, which involves either severing or fixing the tendon in place (referred to as tenotomy or tenodesis), may or may not take place. By doing this, the patient’s expectations after surgery can be appropriately managed before the operation takes place.