Bicipital Tendonitis

THE CLINICAL SYNDROME

The tendons of the long and short heads of the biceps either alone or together are particularly prone to the development of tendonitis, which is known as bicipital tendonitis. The etiology of this syndrome is usually at least in part due to impingement on the tendons of the biceps at the coracoacromial arch. The onset of bicipital tendonitis is usually acute, occurring after overuse or misuse of the shoulder joint. Inciting factors may include activities such as trying to start a recalcitrant lawn mower, practicing an overhead tennis serve, or overaggressive follow through when driving golf balls. The biceps muscle and tendons are susceptible to trauma and to wear and tear from overuse and misuse as mentioned. If the long head of the biceps can rupture, leaving the patient with a telltale “Popeye” biceps (named after the cartoon character with the unique biceps). This deformity can be accentuated by having the patient perform Luningston’s maneuver, which is having the patient place his or her hands behind the head and flex the biceps muscle.

SIGNS AND SYMPTOMS

The pain of bicipital tendonitis is constant and severe and is localized in the anterior shoulder over the bicipital groove. A catching sensation may also accompany the pain. Significant sleep disturbance is often reported. The patient may attempt to splint the inflamed tendons by internal rotation of the humerus, which moves the biceps tendon from beneath the coracoacromial arch. Patients with bicipital tendonitis will exhibit a positive Yergason’s sign, which is production of pain on active supination of the forearm against resistance with the elbow flexed at a right angle. Bursitis often accompanies bicipital tendonitis.

Palpatation of the bicipital groove will exacerbate the pain of bicipital tendinitis.

In addition to this pain, patients suffering form bicipital tendonitis will often experience a gradual decrease in functional ability with decreasing shoulder range of motion, making simple everyday tasks such as hair combing, fastening a brassiere, and reaching overhead quite difficult. With continued disuse, muscle wasting may occur and a frozen shoulder may develop.

TREATMENT

Initial treatment of the pain and functional disability associated with bicipital tendonitis should include a combination of the nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may also be beneficial. For patients who do not respond to these treatment modalities, the following injection technique with local anesthetic and steroid may be a reasonable next step.

Injection for bicipital tendonitis is carried out by placing the patient in the supine position. The arm is then externally rotated approximately 45 degrees. The coracoid process is identified anteriorly. Just lateral to the coracoid process is the lesser tuberosity. The lesser tuberocity will be more easily palpated as the arm is passively rotated. The point overlying the tuberocity is marked with a sterile marker.

The musculotendinous unit of the shoulder joint is susceptible to the development of tendonitis for several reasons. First, the joint is subjected to a wide range of motions that are often repetitive in nature. Second, the space in which the musculotendinous unit functions is restricted by the coracoacromial arch, making impingement a likely possibility with extreme movements of the joint. Third, the blood supply to the musculotendinous unit is poor, making the healing of microtrauma more difficult. All of these factors can contribute to tendonitis of one or more of the tendons of the shoulder joint. Calcium deposition around the tendon may occur if the inflammation continues, making subsequent treatment more difficult. Tendonitis of the biceps tendon frequently coexists with bursitis of the associated bursae of the shoulder joint, creating additional pain and functional disability.

This injection technique is extremely effective in the treatment of pain secondary to the aforementioned causes of shoulder pain. Coexistent bursitis and arthritis may also contribute to shoulder pain and may require additional treatment with a more localized injection of local anesthetic and methylprednisolone acetate steroid. This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. Vigorous exercises should be avoided because they will exacerbate the patient’s symptomatology. Simple analgesics and the nonsteroidal anti-inflammatory drugs or a cyclooxygenase-2 inhibitor may be used concurrently with this injection technique.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue. Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age–related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.