Proximal Biceps Tendinopathy

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Proximal Biceps Tendinopathy

Tendinopathy of the Long Head of the Biceps

Tendinopathy is a chronic condition that often follows an initial inflammatory stage called tendonitis. While tendonitis specifically involves inflammation of the tendon, tendinopathy is a broader term that includes cases where the tendon may not necessarily be inflamed but shows degenerative changes. Proximal biceps tendinopathy characterises a clinical condition that impacts the tendon of the long head of the biceps muscle as it moves through the bicipital groove. The spectrum of clinical manifestations spans from acute inflammatory tendonitis to degenerative tendinopathy.

Proximal biceps tendinopathy is thought to arise from overuse of the shoulder, particularly in overhead activities. When it occurs in young individuals, athletic activities that involve repetitive lifting, throwing, and swimming are considered risk factors. In contrast, degenerative tendinopathy and rupture are more often found in those over the age of 60.

The long head of the biceps brachii tendon is a common source of pain in the shoulder. The tendon of the long head of the biceps arises intra-articularly from the supraglenoid tubercle and superior glenoid labrum and crosses over the humeral head. It then exits the capsule and passes downwards within the bicipital groove, anchored by the transverse humeral ligament and covered by the tendon of the pectoralis major.

The bicipital groove is an anatomic landmark that is positioned between the greater and lesser tuberosities, playing a crucial role in maintaining the stability of the proximal biceps tendon. Historically, the transverse humeral ligament was believed to have a central role in ensuring the stability of the bicipital groove. However, in recent studies, its significance in maintaining stability has been challenged, and several authors have raised doubts about its status as a clearly defined anatomical structure. This viewpoint continues to be a subject of debate, with the majority of current studies suggesting that the transverse humeral ligament, at most, represents a continuation of fibres originating from the subscapularis, supraspinatus, and coracohumeral ligaments.

Because of its intra-articular course, injury to the biceps tendon is often accompanied by other shoulder conditions involving capsular, labral, and rotator cuff structures. In addition, rupture of the transverse humeral ligament may result in a painful slipping of the tendon from the bicipital groove during external and internal rotation of the shoulder while the muscle is under tension.

Causes of proximal biceps tendinopathy may include overload during eccentric contraction of the biceps muscle (e.g., lowering one’s body during the descent phase of a pull-up), repetitive overhead activities (e.g., swimming), and existing subacromial impingement which makes the proximal biceps more vulnerable to injury. Proximal biceps tendinopathy is often accompanied by rotator cuff or labral tears (SLAP lesions).

Biceps Tendon Tear

When the tendon of the biceps muscle tears or detaches from its attachment points, it can lead to the retraction of the muscle. This leads to a characteristic bulge of the lower anterior arm known as a “popeye deformity”. Tendon tears typically occur in older individuals who have long-standing degenerative tendinopathy. A tear may result from a single provocative incident involving a strong contraction of the muscle. This leads to pain, a “popping” sensation, immediate loss of strength, and the appearance of a muscle bulge. Subsequent bruising in the upper arm helps to confirm the diagnosis.

• Anterior shoulder pain that is localized in the bicipital groove when performing overhead activities
• Patients often point directly to the location of the injured biceps tendon
• Pain that is described as “throbbing” when acute
• Pain that is aggravated by contraction of the biceps
• Nocturnal pain is often reported
• Pain that is relieved by rest and the application of ice

• Tenderness elicited on palpation of the proximal portion of the tendon of the long head of the biceps at the bicipital groove
• Pain produced on resisted elbow flexion
• The Speed’s and Yergason’s tests are often positive

Diagnostic Ultrasound – Diagnostic ultrasound has high sensitivity and specificity for complete tears of the tendon of the long head of the biceps, but has limited accuracy for partial tears and tendinopathy.

Plain Radiography – Plain radiography is of little help in assessing biceps tendinopathy and rupture, but may show confounding shoulder pathologies (e.g., subacromial spurring or anatomic variants of the acromion).

MRI – MRI is of value in identifying the presence of concomitant pathologies such as rotator cuff and labral tears but is of limited value in demonstrating biceps tendinopathy.

The following are examples of red flags for patients presenting with shoulder pain:

• History of a significant injury
• Severe pain
• Unrelenting pain
• Nocturnal pain
• Joint Instability
• Deformity
• Significant swelling or bruising
• Presence of tingling, numbness, burning, or other neurological impairment
• Loss of distal arm pulses
• Significant loss of range of motion
• Severe tenderness on palpation or severe pain with any examination procedure
• Unexplained weight loss

If any red flags are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.

Ice or Heat?

Some practitioners advocate using moist heat in the subacute or chronic phase. However, we have found that patients often benefit from the continued application of ice to reduce discomfort and manage inflammation. The application of ice helps to decrease the patient’s pain which then allows them to tolerate some movement at the location of the injury. This helps the patient to maintain range of motion, stimulates circulatory perfusion, and prevents potential atrophy, all of which help to speed recovery.

Heat therapy may not be the best option for proximal biceps tendinopathy. Proximal biceps tendinopathy may involve inflammation (tendonitis). Applying heat can potentially increase blood flow to the area and make the inflammation worse, leading to more pain and discomfort. Whilst heat therapy may provide temporary pain relief, by relaxing muscles and increasing blood flow, it does not address the underlying cause of the tendinopathy. Therefore, the use of heat therapy may delay recovery.

Anterior Shoulder Pain Caused by Myofascial Pain Syndrome

In patients presenting with anterior shoulder pain, a complete clinical examination should include an evaluation of the following muscles for the presence of myofascial pain syndrome as the concomitant or primary cause of the patient’s pain:

• Infraspinatus (commonly involved but often overlooked)
• Pectoralis major and minor
• Supraspinatus
• Deltoid
• Biceps brachii

• The trigger points associated with myofascial pain syndrome may be located anywhere within a muscle and its fascia. Therefore, the entire muscle should be examined thoroughly. However, based on our clinical experience, the common locations for trigger points are presented in the images below.