Biceps Tendinopathy/Tear

Biceps Tendinopathy/Tear

Causes

Biceps tendinopathy or a biceps tendon tear can occur due to several factors, often related to repetitive stress, overuse, or degenerative changes in the tendon. Here are the primary causes:

1. Repetitive Overuse: Activities that involve repetitive overhead motions or repetitive use of the arm can strain the biceps tendon over time. This is common in athletes who participate in sports such as baseball (pitchers), tennis, swimming, and weightlifting.

2. Age-Related Changes: As individuals age, tendons naturally undergo degenerative changes, becoming less elastic and more prone to injury. This can predispose older adults to biceps tendinopathy or tears.

3. Poor Biomechanics: Incorrect technique or biomechanics during sports or physical activities can place excessive stress on the biceps tendon. Improper lifting techniques, especially heavy lifting without proper form, can also contribute to tendon damage.

4. Direct Trauma: A sudden forceful impact or injury to the shoulder or elbow can lead to a biceps tendon tear. This can occur during falls, accidents, or contact sports.

5. Shoulder Instability: Instability in the shoulder joint, such as from shoulder dislocations or chronic shoulder instability, can place abnormal stress on the biceps tendon. This may increase the risk of tendinopathy or tears.

6. Degenerative Changes: Conditions like osteoarthritis or inflammatory arthritis affecting the shoulder joint can lead to degeneration of the biceps tendon, making it more susceptible to injury.

7. Previous Injuries: A history of shoulder or elbow injuries, including prior biceps tendonitis or tendinopathy, can weaken the tendon and increase the risk of further injury.

8. Overloading: Training too intensively without adequate rest or recovery periods can lead to overloading of the biceps tendon, increasing the risk of tendinopathy or tears.

Symptoms

- Pain: Pain is typically the most prominent symptom. The location of the pain can vary:
- Biceps Tendonitis: Pain is often felt at the front of the shoulder and may radiate down the arm to the elbow. It can be sharp or dull and may worsen with overhead activities or lifting.
- Biceps Tendon Tear: Pain may be sudden and severe, especially if the tear is acute. There may be a snapping or popping sensation at the time of injury. Chronic tears can cause more persistent, deep ache in the shoulder or front of the arm.

- Tenderness: Palpation over the biceps tendon, which runs from the front of the shoulder through the upper arm to attach to the forearm bones, may elicit tenderness.

- Swelling: Inflammation of the tendon can lead to localized swelling around the front of the shoulder or upper arm.

- Weakness: Weakness in the affected arm, particularly with activities that involve bending the elbow against resistance or lifting objects overhead.

- Decreased Range of Motion: Difficulty with shoulder movement, especially overhead movements or reaching behind the back.

- Popping Sensation: Some individuals may experience a popping or clicking sensation in the shoulder, especially with certain movements.

- Cramping: Cramping or spasms in the biceps muscle or surrounding muscles can occur, especially after activity.

- Difficulty Sleeping: Pain and discomfort may interfere with sleep, particularly when lying on the affected side or with certain arm positions.

Diagnosis

Clinical Evaluation:

- 1. Patient History:

- Symptoms: Pain in the front of the shoulder, tenderness over the biceps tendon, weakness, and sometimes a "popping" sound.

- Onset: Understanding whether the pain is acute (suggestive of a tear) or chronic (suggestive of tendinopathy).

- Activity Level: Assessing activities that exacerbate symptoms, such as overhead movements.

2. Physical Examination:

- Inspection: Looking for signs of swelling, bruising, or a visible bulge in the upper arm (Popeye sign) which can indicate a tear.

- Palpation: Feeling for tenderness over the biceps tendon.

- Range of Motion: Checking for any limitations in shoulder and elbow movements.

- Strength Testing: Evaluating muscle strength in the shoulder and elbow.

- Special Tests:

- Speed's Test: The patient resists a downward force with the arm extended and palm facing up. Pain suggests biceps tendinopathy.

- Yergason's Test: The patient flexes the elbow and attempts to supinate the forearm against resistance. Pain or a snapping sensation suggests issues with the biceps tendon.

- Hook Test: Used to diagnose a distal biceps tendon tear; the examiner attempts to hook their finger under the biceps tendon at the elbow.

Imaging Studies

1. Ultrasound: Useful for visualizing the tendon structure and identifying tears or inflammation.
2. Magnetic Resonance Imaging (MRI): Provides detailed images of soft tissues, including the biceps tendon and surrounding structures. Can help differentiate between partial and complete tears.

3. X-Rays: Generally used to rule out bone-related issues or other causes of shoulder pain.

Laboratory Tests - Rarely needed, but may be considered if there's suspicion of systemic conditions like rheumatoid arthritis or infections that could contribute to tendon issues.

Differential Diagnosis - Consider other conditions that can mimic biceps tendinopathy or tear, such as rotator cuff tears, labral tears, shoulder impingement, and adhesive capsulitis.

Treatments

Conservative Treatments

1. Rest and Activity Modification:
- Avoid activities that exacerbate symptoms, especially overhead movements and heavy lifting.
2. Ice and Heat Therapy:
- Apply ice packs to the affected area for 15-20 minutes several times a day to reduce inflammation.
- Use heat therapy (e.g., warm compresses) to relax muscles and improve blood flow.
3. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):
- Medications like ibuprofen or naproxen can help reduce pain and inflammation.
4. Physical Therapy:
- Stretching and Strengthening Exercises: Focus on improving flexibility and strengthening the muscles around the shoulder and elbow.
- Manual Therapy: Techniques to improve joint mobility and reduce muscle tightness.
- Eccentric Loading Exercises: Specifically beneficial for tendinopathy, as they help remodel the tendon.
5. Corticosteroid Injections:
- Used in some cases to reduce severe inflammation and pain. However, repeated use can weaken the tendon.
6. Platelet-Rich Plasma (PRP) Therapy:
- Involves injecting a concentration of the patient's own platelets to promote healing of the tendon.

Surgical Treatments

1. Biceps Tenotomy:
- The surgeon releases the damaged part of the tendon from its attachment point, which can relieve pain. This procedure can result in a "Popeye" deformity but generally maintains shoulder function.
2. Biceps Tenodesis:
- The surgeon reattaches the biceps tendon to a different part of the humerus, maintaining the length-tension relationship of the muscle and preventing deformity.
3. Repair of Biceps Tendon Tear:
- In cases of complete distal biceps tendon tears, surgical repair involves reattaching the tendon to the radial tuberosity.

Rehabilitation

1. Post-Surgical Rehabilitation:
- Initial immobilization followed by a gradual increase in range of motion exercises.
- Strengthening exercises start once healing progresses, usually several weeks post-surgery.
2. Return to Activity:
- Gradual return to sports or heavy lifting, usually 3-6 months after surgery, depending on the extent of the injury and the type of surgery performed.