Definition

The precise definition of biceps tendinitis remains elusive. Biceps tendinitis can be further delineated on the macroscopic levelinto tendinitis and tenosynovitis. Tendinitis represents an alteration in the structure of the tendon and can be atrophic, hypertrophic,frayed, or inflammatory.^1,2 Tenosynovitis reflects an inflamed tendon sheath often with a normal tendon. Tenosynovitisis usually reversible through nonoperative means, whereas tendinitis is more recalcitrant to conservative treatment.¹

Etiology

Biceps tendinitis can be subdivided into primary tendinitis and secondary tendinitis.

Primary biceps tendinitis
Primary biceps tendinitis is a rare phenomenon that occurs in the form of a tenosynovitis caused by recurrent gliding of the humerusaround the biceps tendon (Slide 1A and Slide 1B). The tendon invariably appears normal. Primary biceps tendinitis is usually reversible throughnonoperative means including rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and intra-articular corticosteroidinjections.¹

SLIDE 1A		SLIDE 1B

Secondary biceps tendinitis
Secondary biceps tendinitis is caused by underlying shoulder disease. The underlying pathology can be intra-articular,within the bicipital groove, related to the rotator cuff, or related to biceps instability.^1,2

Intra-articular diseases (e.g., inflammatory arthropathies, osteoarthritis, and osteochondromatosis) often result in hypertrophictendinitis. Nonoperative treatment results in only transitory relief unless the underlying diagnosis is addressed. Operative treatmentincludes addressing the underlying pathology and the biceps via tenotomy or tenodesis.

Pathology of the bicipital groove occurs in the form of an osteophyte on the medial wall (Slide 2).The osteophyte may be degenerative in origin or, more commonly, related to previous trauma of the lesser tuberosity.This results in a mechanical wearing of the tendon with severe fraying. Nonoperative treatment usually results in transient reliefand biceps tenotomy or tenodesis is necessary.

Slide 2

Pathology of the rotator cuff represents the most common cause of biceps tendinitis and is classified by the type of underlying lesion. Superior one-third lesions of the subscapularis can cause inflammation and distension of the ligamentous pulley andbicipital sheath, ultimately destabilizing the biceps within its groove (Slide 3).

Slide 3

Articular-sided, partial thickness tears of the supraspinatus, as observed with the repetitive contact of internal impingement inthrowing athletes, can result in a mechanical abrasion of the lateral aspect of the biceps as the tendon "rides up" ontothe greater tuberosity during the follow-through phase of throwing (Slide 4).³

Slide 4

Degeneration and tearing limited to the coracohumeral ligament and rotator interval can result in inflammation of the bicepstendon and fraying of its superior aspect from mechanical friction of the tendon against the coracoacromial arch (Slide 5).

Slide 5

Large tears of the rotator cuff, including disruption of the supraspinatus, infraspinatus, and rotator interval, invariably lead to somedegree of biceps disease.² Once the infraspinatus is disrupted, proximal migration of the humeral head occurs andentraps the biceps tendon between the humeral head and coracoacromial arch, resulting in mechanical pain with elevation of the arm.

The success of nonoperative treatment of biceps tendinitis that occurs secondary to rotator cuff pathology is dependent uponthe type of rotator cuff pathology present. In the younger patient with the superior one-third subscapularis lesion or in the throwingathlete, relief from nonoperative treatment is usually transitory. Overall, nonoperative treatment in these patients is disappointing,and the tendinitis may evolve into a spontaneous biceps rupture. For the older patient who does not have arthritis and who is moreprone to develop lesions of the supraspinatus/infraspinatus and/or the rotator interval, periodic subacromial corticosteroid injectionsmay yield acceptable results and thereby avoid surgery. Additionally, in the subset of patients with proximal migration of the humeralhead, physiotherapy can be instituted to attempt to re-educate muscle groups outside of the rotator cuff (latissimus dorsi and teresmajor) to act in depression of the humeral head during arm elevation. Results of such therapy programs are unknown. Patients whofail nonoperative treatment are candidates for biceps tenotomy or tenodesis performed in combination with rotator cuff surgery(repair vs. debridement and acromioplasty).⁴

Instability of the biceps tendon results in biceps tendinitis. Instability can occur as subluxation, a transitory or partial loss ofcontact between the biceps tendon and the bicipital groove, or dislocation, fixed or complete loss of contact between the bicepstendon and the bicipital groove (Slide 6A and Slide 6B).⁵With the exception of a throwing athlete, biceps subluxation occurs in a medial direction via disruption or distension of the ligamentouspulley resulting in fraying of the medial aspect of the biceps tendon. The most important component of nonoperative treatment forbiceps subluxation is avoidance of repetitive elevation (loss of gliding mechanism).

SLIDE 6A		SLIDE 6B

Dislocation of the biceps tendon occurs with the tendon resting on the lesser tuberosity (partial tear of the subscapularis), thetendon dislocated intra-articularly (complete rupture of the subscapularis), or with the tendon dislocated extra-articularly and restingon the anterior surface of the subscapularis (subscapularis intact and disruption of the rotator interval)(Slide 7A, Slide 7B and Slide 7C).When the tendon is resting on the lesser tuberosity, mechanical friction on the tendon will evolve to spontaneous rupture.With the latter two types of dislocation, absence of mechanical friction prevents spontaneous rupture. In addition to traditionalnonoperative treatment (rest, NSAIDs, and injections), operative interventions aimed at relocating the biceps have beenattempted.² However, the results of this conservative approach to the dislocated biceps were disappointing, andthe procedure has been abandoned. Operative treatment for the unstable biceps tendon consists of tenotomy or tenodesis.

SLIDE 7A		SLIDE 7B		SLIDE 7C

Summary

When considering treatment for chronic proximal biceps tendinitis, physicians must understand the cause of the tendinitis.Primary biceps tendinitis can be reversible with appropriate nonoperative management. In the more common secondary bicepstendinitis, symptomatic improvement from nonoperative treatment is often transitory and ultimate relief may only come fromaddressing the underlying pathology and tenotomy or tenodesis of the biceps.

References

1. Burkhead WZ Jr, Arcand MA, Zeman C, et al. The biceps tendon. In: Rockwood CA, Matsen FA. eds. The Shoulder. 2nd ed. Philadelphia, Pa: WB Saunders; 1998:1009-1063.
   
    
2. Habermeyer P, Walch G. The biceps tendon and rotator cuff disease. In: Burkhead WZ, ed. Rotator Cuff Disorders. Baltimore, Md: Williams and Wilkins; 1996:142-159.
   
    
3. Walch G, Boileau P, Noel E, et al. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg. 1992; 1:238-245.
   
    
4. Walch G, Nové-Josserand L, Boileau P, et al. Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg. 1998; 7:100-108.
   
    
5. Walch G, Madonia G, Puzzi I, Riand N, Levigne C. Arthroscopic tenotomy of the long head of the biceps in rotator cuff ruptures. In: Gazielly DF, Gleyze P, Thomas T, eds. The Cuff. Paris, France: Elsevier; 1997:350-355.