THE CLINICAL SYNDROME

• Tendinitis is especially likely to manifest itself in the tendons that attach the long head of the biceps to the short head of the biceps.

• Impingement on the tendons of the biceps that occurs at the coracoacromial arch is the typical cause, or at least a contributing factor, in biceps tendon tears.

• The onset of pain and functional disability associated with a biceps tendon tear is generally sudden and occurs after overuse or misuse of the shoulder joint.

• For example, trying to start a lawn mower that won't start, practicing an overhead tennis serve, or performing an overaggressive follow-through when driving golf balls are all examples of activities that can cause this type of injury.

• The proximal rupture of the tendon of the long head of the biceps tendon accounts for more than 97% of biceps tendon ruptures; ruptures of the distal portion of the biceps tendon occur less than 3% of the time.

  • This type of tendon rupture is more common in men.

• A rupture of the long head of the biceps tendon typically takes place between the ages of 40 and 60, but it can also take place in younger age groups when those age groups participate in high-risk activities like snowboarding.

SIGNS AND SYMPTOMS

• The majority of patients experience an abrupt onset of pain when they tear their biceps tendon, which is often accompanied by a popping or cracking sound.

• The pain is continuous and excruciating, and it is centered in the front of the shoulder, directly above the bicipital groove.

• In the event that the trauma is severe and recent, ecchymosis may be present.

• It is frequently reported that significant sleep disturbances occurred.

• Patients who have a partial tendon tear and significant tendinitis may try to splint the affected shoulder by internal rotating the humerus.

  • This moves the biceps tendon from beneath the coracoacromial arch, which stabilizes the shoulder.

  • However, this is not a recommended treatment option.

• Patients who have a tear in their biceps tendon have a positive result on the Ludington test, as was previously described.

• Bursitis and tendinitis are common complications that occur alongside biceps tendon tears.

• Patients who have an acute tear of the long tendon of the biceps may only experience vague discomfort at times, and the only reason they seek medical attention is due to the cosmetic abnormality of retracted biceps tendon and muscle.

• Shoulder stiffness can occasionally occur if the condition is left untreated.

TESTING

• Radiographs in the plain format should be taken of every patient who comes in complaining of shoulder pain.

• The clinical presentation of the patient may suggest the need for additional testing, which may include an evaluation of the patient's complete blood count, erythrocyte sedimentation rate, and antinuclear antibody levels.

• When tendinopathy or a tear of the biceps tendon in the shoulder is suspected, magnetic resonance imaging (MRI) of the shoulder should be performed.

• Imaging with ultrasound can also be helpful in further defining the pathology that is causing the patient's pain and the functional disability they are experiencing.

• The method of injection that will be described in more detail later acts as both a diagnostic tool and a treatment strategy.

DIFFERENTIAL DIAGNOSIS

• In most cases, a biceps tendon tear can be easily diagnosed through clinical examination.

  • However, a coexisting case of bursitis or tendinitis in the shoulder that was caused by overuse or improper use may make the diagnosis more complicated.

• On occasion, a partial tear of the rotator cuff can be misdiagnosed as a tear of the biceps tendon.

• Shoulder, superior sulcus of the lung, and proximal humerus tumors are some of the clinical conditions that should be taken into consideration in certain instances.

• Pain associated with acute herpes zoster, which develops prior to the appearance of a vesicular rash, can be mistaken for pain associated with a biceps tendon tear.

TREATMENT

• The initial treatment for the pain and functional disability associated with a biceps tendon tear consists of a combination of physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors.

• Both of these classes of medications are considered COX-2 inhibitors.

• The application of heat and cold to specific areas of the body may also be beneficial.

• The injection of a local anesthetic and steroid is a reasonable next step for patients who do not respond to these treatment modalities and who appear to have significant local pain in the region of the bicipital groove.

• When administering an injection to treat a biceps tendon tear, the patient is positioned in the supine position with their arm externally rotated about 45 degrees before the procedure begins.

• The anterior region is where the coracoid process can be found.

• When the arm is passively rotated, the lesser tuberosity, which is located just laterally to the coracoid process, is in a position where it is easier to palpate.

• A sterile marker is used to mark the point that lies directly on top of the tuberosity.

• An antiseptic solution is used to prepare the skin that is located over the front of the shoulder.

• A sterile syringe with 1 milliliter (mL) of bupivacaine that does not contain any preservatives and 40 milligrams (mg) of methylprednisolone is threaded onto a needle that is 11.2 inches long and 25 gauges in diameter using aseptic technique.

• The point that had been marked earlier is palpated, and the insertion of the biceps tendon is located again using the gloved finger.

• At this point, the needle is advanced very carefully through the skin, the subcutaneous tissues, and the tendon that lies underneath it until it impinges on bone.

• After that, the needle is pulled back approximately one to two millimeters from the periosteum of the humerus, and a gentle injection of the contents of the syringe is performed.

  • It is normal to feel some resistance when the injection is given.

  • If the needle passes through the joint space without meeting any resistance, either the tendon or the joint space itself has been ruptured.

  • If there is a significant amount of resistance, the needle tip is most likely embedded in the substance of a ligament or tendon.

• In this case, the needle should be moved slightly in either direction until the injection can be continued without a significant amount of resistance.

• After the needle has been removed, a sterile pressure dressing and an ice pack are applied to the area that was just given the injection.

COMPLICATIONS AND PITFALLS

• If the clinically relevant anatomy is carefully considered before administering the injection, this method does not pose a safety risk.

• In order to prevent infection, sterile technique must be utilized, and universal precautions must be taken in order to lessen the likelihood that the operator will be put in harm's way.

• If pressure is applied to the injection site immediately after the injection, this can help reduce the risk of complications such as ecchymosis and hematoma formation.

• Infection is the most serious risk associated with this method of injecting, but if proper asepsis procedures are followed, the likelihood of contracting an infection should be extremely low.

• In addition, there is a chance that the injection itself will cause injury to the biceps tendon.

• If a tendon that is already severely inflamed or has been damaged in the past is given an injection directly, there is a risk that it will rupture.

• This complication can usually be avoided if the clinician employs a gentle technique and ceases injecting the patient as soon as they encounter significant resistance.

• Patients should be made aware of the possibility that they may experience a temporary increase in pain after receiving an injection, as this affects approximately one quarter of all patients.