Biceps Tendinopathy

What are the signs & symptoms of biceps tendinopathy?

Biceps tendinopathy involves the irritation followed by inflammation of the long head of biceps tendon which is located in the front of the arm.

There are a few different types of tendinopathy which include; tendinitis, tendinosis, paratendonitis and tendon rupture. Tendinitis refers to an inflammatory pathology, whilst tendinosis denotes a degenerative tendon condition, which is sometimes accompanied by inflammation. Paratendonitis occurs when there is inflammation within the sheath that surrounds the tendon. Tendinopathy generally causes diminished function of the involved joint and muscle, in this instance the biceps tendon, localized swelling, tissue irritation, redness and tenderness and a gradual onset of morning stiffness, usually lasting less than 30 minutes. Further clinical signs include pain, weakness and restricted range of motion of the shoulder joint.

• Diminished muscle and shoulder joint function.
• Redness, tenderness and localized swelling around the arm and front of the shoulder.
• Morning stiffness within the shoulder lasting less than 30 minutes
• Pain, weakness and restricted range of motion of the shoulder.
• Crepitus and clicking in and around the shoulder.

Biceps tendinopathy seems to affect more the athletic population of age between 18-35 and people over the age of 65. Athletes involved in sports requiring repetitive shoulder and arm movements, especially overhead actions are more susceptible to biceps tendinopathy. Direct trauma to the shoulder and rotator cuff pathologies from sports including rugby, tennis, baseball, gymnastics, martial arts and weightlifting can lead to biceps tendinopathy.

Primary biceps tendinopathy involves the inflammation of the biceps tendon within the bicipital groove and this occurs in 5% of patients. The rest of the cases involve a secondary impingement of the tendon which is accompanied by scapular and shoulder instability and capsular laxity or tightness. Biceps tendinopathy is often accompanied by other shoulder pathologies including shoulder impingement, rotator cuff injuries, and shoulder instability.

• Associated injuries:
• Rotator cuff pathologies
• Scapular instability
• Shoulder instability
• Shoulder impingement
• Shoulder bursitis

Biceps tendinopathy is diagnosed by understanding the symptoms of the patient by taking an extensive case history. This is then followed by a thorough examination of the shoulder joint and muscles using palpation and orthopaedic testing. The hands-on examination involves active and passive movements of the shoulder and elbow, followed by strength testing of the muscles and provocative tests to load the biceps tendon and reproduce the symptoms.

In some cases, imaging may be used. Imaging techniques include ultrasound, MRI and radiography looking for signs of tendon sheath swelling and fluid accumulation.

There are many different treatment options for biceps tendinopathy ranging from conservative therapy to invasive surgical therapy.Biceps tendinopathy can be ongoing for a long time if not correctly treated.

Conservative treatment

Medication. Such as nonsteroidal anti inflammatories (NSAIDs) aer used to help control inflammation and pain levels. It is best to talk to your doctor as they will advise and prescribe you the best medication for your symptoms.

Corticosteroid Injection. This procedure is carried out by your doctor and involves injection of a local anesthetic along with a steroid injection along the tendon. This therapy is used to help decrease the inflammation and speed up the recovery of the tissues.

Surgical Management

Surgical intervention is often used with higher functional level patients and athletes, or those where conservative therapy has not worked. Surgery is normally performed arthroscopically, this is where small incisions are made into the shoulder joint and an arthroscope is inserted into the shoulder. This type of surgery allows the surgeon to assess the shoulder joint including the condition of the biceps tendon using small tools and cameras that are inserted into the arthroscope.

Biceps Tenodesis. During this procedure the damaged section of the tendon is removed and the remaining part of the tendon is reattached to the arm bone (humerus).

Tenotomy. In more severe cases where the tendon is too damaged to be repaired the surgeon may opt to release the tendon from its attachment to the glenoid labrum ( part of the shoulder joint). This is one of the least invasive surgeries however, it may result in a ‘popeye’ type bulge on the upper arm.

The overall negative effects of surgery is that it can damage the fascia surrounding the tissues of the shoulder joint. Fascia is a thin connective tissue that surrounds the muscles and tendons and prevents them from rubbing together. For this reason there is a small chance that some symptoms and discomfort might not completely disappear in the affected shoulder region.

The prognosis for recovery from biceps tendinopathy depends on the level and stage of injury of the tendon. A minor bicep tendinopathy can take up to two weeks to completely recover whilst an ongoing bicep tendinopathy with more tissue damage can take anything between two and six months to completely resolve.

The best way to prevent biceps tendinopathy is by:

• maintaining good range of motion of the scapula, shoulder and elbow joint,
• stretching the involved muscles pre- and post-workout whilst strengthening the surrounding structures including the rotator cuff, triceps, deltoids and forearm muscles.

Swimming can be a great form of exercise to improve the circular range of motion of the shoulder joint whilst engaging all the surrounding muscles. Finally, strength training with the use of elastic bands can improve the muscle strength in many different planes of movement and muscle lengths, whilst stabilizing the shoulder and elbow joint and improving joint proprioception.

The best rehabilitation approach for biceps tendinopathy starts with the unloading phase of the tendon. Isometric exercises are used which engage the muscle without causing any shortening or lengthening of the muscle belly or tendon.

The second stage of rehab uses eccentric exercises. The muscle is again activated but this time during the contraction the muscle is slowly lengthened. This allows the tendon to load and stretch at the same time.

The final stage is concentric exercises involving contraction and muscle shortening, fully engaging the tendon of the biceps. Other forms of rehab may use elastic bands to strengthen and stretch the muscle, whilst activating the proprioceptive mechanisms of the muscle improving the muscle and joint stability.

People experiencing bicep tendinopathy usually consult a physiotherapist or an osteopath. With the right management and depending on the severity of the injury most patients return to normal activities within a few weeks.

There is often no reason to visit your GP or go to hospital as biceps tendinopathy is a purely musculoskeletal injury. If the primary practitioner believes that there is something else causing the shoulder pain or if the pain is getting worse, they will refer them to their GP for further imaging. The practitioner may also refer you to your GP with a referral letter giving an insight of the patient’s current situation and needs.

Would you like to know whats the difference Osteopathy, Physiotherapy and Chiropractic?

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