History

Fact Explanation
Shoulder pain Deep and aching pain in the anterior shoulder. This pain gets worsen at night and if sleeps on the affected shoulder. Pain is exacerbated by lifting or elevated pushing or pulling. Pain is attributed to the inflammation of the tendon around the long head of the biceps muscle.Pain starts or increases with repetitive overhead movements. The pain may localize or may radiate laterally or downwards due to the inflammation may affect the deltoid. Sometimes inflammation may spread down the tendon in to the belly of the biceps muscle which causes radiating pain downwards. Apart from the inflammation, bicipital tendinitis may occur due to overuse or degeneration especially in athletes and in old age. (1)
Reduced range of movements (ROM) in the shoulder Movements cause more pain.So the range of movements is limited. [1]
Audible popping If the inflammation is accompanied by a rupture of the biceps tendon, patient may complain of an audible popping which is painful.Pain is relieved following the pop. [1]
Can occur secondary rotator-cuff disorders and intra-articular problems like SLAP (superior labrum anterior to posterior) lesions All of them are risk factors for biceps rupture along with recurrent tendinitis, contralateral biceps tendon rupture, rheumatoid arthritis and age older than 40 years. [1]
Absence of a traumatic injury is helpfull in differentiating from SLAP (superior labrum anterior to posterior) lesions which usually follows a trauma, such as a direct blow to the shoulder or a fall on an outstretched hand. [1]
References
  1. CHURGAY,M.D, A.CATHERINE Diagnosis and Treatment of Biceps Tendinitis and Tendinosis, Am Fam Physician.2009,80(5),470-476.[viewed 5 April 2014]. Available from: http://www.aafp.org/afp/2009/0901/p470.html

Examination

Fact Explanation
Tenderness over the bicipital groove [1] The inflamed bicipital tendon exits the joint within the bicipital groove of the humerus in 10 degree internal rotation. Palpation of that part causes pain.
Speed’s test [1,2] Positive in bicipital tendinitis. Pain in the bicipital groove is reproduced in flexing the shoulder against resistance with elbow extended and forearm supinated. This pain is due to the inflammation.Sensitivity of the test is 32%, whereas the specificity is 75%.[3]
Yergason's Test [1,2] The patient is asked to externally rotate and supinate his arm against the manual resistance. Test is considered positive if pain is reproduced in the bicipital groove during the test.It has a 43% of sensitivity and 79% of specificity. [3]
Bruise in the anterior shoulder [1] Bruise appears if there is an accompanied tear in the biceps tendon.A bulge in the The upper elbow area may be visible as the muscle retracts distally from the rupture point.
References
  1. CHURGAY,M.D, A.CATHERINE Diagnosis and Treatment of Biceps Tendinitis and Tendinosis, Am Fam Physician.2009,80(5),470-476.[viewed 5 April 2014]. Available from: http://www.aafp.org/afp/2009/0901/p470.html
  2. WOOD,V.J. et al. Glenohumeral muscle activation during provocative tests designed to diagnose superior labrum anterior-posterior lesions.Am J Sports Med. 2011 Dec,39(12),2670-8 [viewed 5 April 2014]. Available from: doi: 10.1177/0363546511419822.
  3. HOLTBY,R, H.RAZMJOU.Accuracy of the Speed's and Yergason's test in detecting bicpes pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy.2004,20(3),231-236.[viewed 5 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15007311

Differential Diagnoses

Fact Explanation
Acromioclavicular arthropathy Shoulder pain localizes over acromioclavicular joint.Range of motion in the shoulder joint is preserved [1,2]
Cervical disk degeneration Pain localizes posteriorly along with hand numbness and weakness. Limited range of motion in neck,intrinsic hand weakness and impaired light touch are associated.[2]
Rotator cuff tendinopathy or tear Pain often localizes anteriorly or laterally.Passive range of motion is preserved.Usually a history of repetitive overuse is present.[2,4]
Superior Labrum Lesions Vague shoulder pain with overhead or cross-body activities is present.Patient may complain of popping, clicking, or catching of the shoulder joint.Pain is associated with weakness or stiffness of the shoulder.[3]
References
  1. WHITE,R.H et al. Shoulder Pain. West J Med, Oct 1982, 137(4), 340–345. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989032/pdf/264_2010_Article_1038.pdf
  2. ANTHONY,E. Adhesive Capsulitis: A Review.Am Fam Physician, 2011 Feb 15,83(4),417-422. [viewed 16 March 2014]. Available from: http://www.aafp.org/afp/2011/0215/p417.html
  3. CHURGAY,M.D, A.CATHERINE Diagnosis and Treatment of Biceps Tendinitis and Tendinosis, Am Fam Physician.2009,80(5),470-476.[viewed 5 April 2014]. Available from: http://www.aafp.org/afp/2009/0901/p470.html
  4. HE'ERI,G.B. et al. Ruptures of the rotator cuff. Can Med Assoc J, 1980 Oct 4, 123,620-627. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705609/

Investigations - for Diagnosis

Fact Explanation
X-ray of the shoulder joint [1] Helps to rule out the bony causes of shoulder impingements,spurs, dislocations and fractures
Ultrasound scan [1,3] Gives better visualization of the extra-articular segment of the biceps tendon
Magnetic resonance imaging (MRI) [1,2,3] Gives better visualization of the intra-articular segment of the biceps tendon
Arthrography [1,3] Is used either as MRI or CT. Shows soft tissue pathologies like tendon subluxations, ruptures and dislocations
Local anesthetic injections [1] If the pain is relieved by an injection of 1% lidocaine (Xylocaine) into the subacromial space, patient is most probably suffering from a rotator cuff tendinitis, but not biceps tendinitis.
References
  1. CHURGAY,M.D, A.CATHERINE Diagnosis and Treatment of Biceps Tendinitis and Tendinosis, Am Fam Physician.2009,80(5),470-476.[viewed 5 April 2014]. Available from: http://www.aafp.org/afp/2009/0901/p470.html
  2. KING,L.J, J.C. HEALY. Imaging of the painful shoulder. Man Ther. 1999, 4(1),11-18.[viewed 5 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10463016
  3. AHRENS,P.M, P.BOILEAU. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007,89(8),1001-1009..[viewed 5 April 2014]. Available from:http://www.bjj.boneandjoint.org.uk/content/89-B/8/1001.long

Management - General Measures

Fact Explanation
Rest [1] Cessation of any offending activities specially repeated overhead movements is the first step of the management.However complete inactivity or immobilization should be avoided
Ice [1] Provides local vasoconstrictive and analgesic effects.Ice should be applied for at least 20 minutes.
Non Steroidal Anti Inflammatory Drugs (NSAIDs) [1,2] The anti inflammatory is useful initially to provide pain relief. Topical application can be supplemented by oral NSAID's.
Corticosteroid injections [1,2,3] Improves pain and functional limitations in the short term.Repeated corticosteroid injections may be needed. Tendon tear is a possible complication.
Physiotherapy [1,2] This is consisted of several steps. Rest, stretching exercises and strengthening exercises. Exercises are started after the shoulder is pain-free.The aim is to regain painless full range of movements.
References
  1. CHURGAY,M.D, A.CATHERINE ADiagnosis and Treatment of Biceps Tendinitis and Tendinosis, American Family Physician.2009,80(5),470-476.[viewed 5 April 2014]. Available from: http://www.aafp.org/afp/2009/0901/p470.html
  2. PATTON,W.C. et al. Biceps tendinitis and subluxation. Clin Sports Med.2001;20(3):505-529.[viewed 5 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11494838
  3. AHRENS,P.M, P.BOILEAU. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007,89(8),1001-1009..[viewed 5 April 2014]. Available from:http://www.bjj.boneandjoint.org.uk/content/89-B/8/1001.long

Management - Specific Treatments

Fact Explanation
Biceps tendon repair Surgery is considered if general management fails after three months. Rapair can be done as an open surgery or arthroscopically. Biceps tendon is repaired and strengthened where it attaches to the glenoid. Structures causing primary and secondary impingement is removed. Debridement is done when necessary. [1,2]
Biceps tenodesis Damaged section of the biceps is removed, and the remaining tendon is reattached to the humerus.The most reliable and mechanically sound procedure has been the keystone or the keyhold technique [2,3]
Biceps tenotomy Tenotomy is done in severe cases. When the long head of the biceps is not possible to repair or tenodese, damaged part of the biceps tendon is released from its attachment. Tenotomy may result in a Popeye bulge in the arm. [1,2]
References
  1. CHURGAY,M.D, A.CATHERINE Diagnosis and Treatment of Biceps Tendinitis and Tendinosis, Am Fam Physician.2009,80(5),470-476.[viewed 5 April 2014]. Available from: http://www.aafp.org/afp/2009/0901/p470.html
  2. FROIMSON,A.I. et al.Keyhole tenodesis of biceps origin at the shoulder. Clin Orthop 1975,112,245-9..[viewed 5 April 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1192640
  3. AHRENS,P.M, P.BOILEAU. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. 2007,89(8),1001-1009..[viewed 5 April 2014]. Available from:http://www.bjj.boneandjoint.org.uk/content/89-B/8/1001.long