Biciptial tendinitis - Clinicals, Diagnosis, and Management

Rheumatology

Clinicals - 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)
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. Reduced range of movements (ROM) in the shoulder
Movements cause more pain.So the range of movements is limited.
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. 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.
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.
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.
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.
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.

Clinicals - Examination

Fact Explanation
Tenderness over the bicipital groove 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.
Tenderness over the bicipital groove
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 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%. Speed’s test
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%.
Yergason's Test 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. Yergason's Test
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.
Bruise in the anterior shoulder 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.
Bruise in the anterior shoulder
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.

Investigations - Diagnosis

Fact Explanation
X-ray of the shoulder joint Helps to rule out the bony causes of shoulder impingements,spurs, dislocations and fractures X-ray of the shoulder joint
Helps to rule out the bony causes of shoulder impingements,spurs, dislocations and fractures
Ultrasound scan Gives better visualization of the extra-articular segment of the biceps tendon Ultrasound scan
Gives better visualization of the extra-articular segment of the biceps tendon
Magnetic resonance imaging (MRI) Gives better visualization of the intra-articular segment of the biceps tendon Magnetic resonance imaging (MRI)
Gives better visualization of the intra-articular segment of the biceps tendon
Arthrography Is used either as MRI or CT. Shows soft tissue pathologies like tendon subluxations, ruptures and dislocations Arthrography
Is used either as MRI or CT. Shows soft tissue pathologies like tendon subluxations, ruptures and dislocations
Local anesthetic injections 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. Local anesthetic injections
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.

Management - Supportive

Fact Explanation
Rest Cessation of any offending activities specially repeated overhead movements is the first step of the management.However complete inactivity or immobilization should be avoided Rest
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 Provides local vasoconstrictive and analgesic effects.Ice should be applied for at least 20 minutes. Ice
Provides local vasoconstrictive and analgesic effects.Ice should be applied for at least 20 minutes.
Non Steroidal Anti Inflammatory Drugs (NSAIDs) The anti inflammatory is useful initially to provide pain relief. Topical application can be supplemented by oral NSAID's. Non Steroidal Anti Inflammatory Drugs (NSAIDs)
The anti inflammatory is useful initially to provide pain relief. Topical application can be supplemented by oral NSAID's.
Corticosteroid injections Improves pain and functional limitations in the short term.Repeated corticosteroid injections may be needed. Tendon tear is a possible complication. Corticosteroid injections
Improves pain and functional limitations in the short term.Repeated corticosteroid injections may be needed. Tendon tear is a possible complication.
Physiotherapy 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.
Physiotherapy
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.

Management - Specific

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.
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.
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
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
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. 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.

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