Orthopedic Teaching Cases 2023, Jan, 18 | 12:00 am

Shoulder and Elbow cases biceps tendonitis

A 30-year-old, right-hand-dominant man presents to clinic complaining of anterior right shoulder pain. There is pain mostly with overhead movement that radiates to the biceps muscle belly. He takes no medications, is otherwise healthy, and works as a car mechanic. He is an avid volleyball player. His examination includes a positive Hawkins test, positive Yerguson’s test, tenderness to palpation over the intertubercular sulcus, and a negative Speed’s test. The rest of the examination is normal. Plain radiographs are normal.

What is the most likely diagnosis?

  1. Long head of the biceps tendonitis

  2. Subscapularis tendon tear

  3. SLAP tear

  4. Subacromial bursitis

  5. Anterior labroligamentous periosteal sleave avulsion (ALPSA)

 

Discussion

The correct answer is (A). Isolated biceps tendonitis tends to occur in young patients who participate in overhead sports. In older patients, it almost always occurs in associations with other pathologies, such as rotator cuff disease, labral pathology, or AC joint problems. Regardless of age, though, biceps tendonitis tends to present with anterior to anteromedial shoulder pain that can radiate to the biceps and is worse with repetitive use.

Subscapularis tendon tears (Answer B) can lead to biceps tendon subluxation out of the intertubercular sulcus, which can lead to irritation and inflammation of the biceps tendon. However, this patient does not have any other symptoms or signs of a subscapularis tear.

A SLAP tear (Answer C) can also be found with biceps tendonitis as the long head of the biceps tendon originates proximally at the superior labrum. However, this patient is not having mechanical symptoms that would be associated with a SLAP tear, and his presentation is more consistent with biceps tendonitis.

Subacromial bursitis (Answer D) is another pathology often found with biceps tendonitis, but the patient’s presentation resembles biceps tendonitis more so than subacromial bursitis.

Anterior labral periosteal sleeve avulsion (ALPSA) (Answer D) occurs most

commonly with an anterior shoulder dislocation when the humeral head causes a Bankart lesion that also pulls the glenoid periosteum off the glenoid bone. This can result in anterior shoulder pain. This patient does not have any evidence of shoulder dislocation, and the presentation is consistent with biceps tendonitis.

Which of the following is not a physical examination finding in biceps tendon pathology?

  1. Positive Speed’s test

  2. Positive Yerguson’s test

  3. Tenderness to palpation over the intertubercular sulcus

  4. Positive apprehension test

  5. Popeye deformity

 

Discussion

The correct answer is (D). The apprehension test is used to help diagnose anterior shoulder instability. It is performed with the patient supine. The examiner abducts the shoulder to 90 degrees, flexes the elbow to 90 degrees, and then externally rotates the shoulder. If the patient experiences a sensation that the shoulder is going to dislocate anteriorly, the test is positive.

Speed’s test (Answer A) is performed by having the patient flex the shoulder to 90 degrees with an extended elbow and supinated forearm. He is then asked to flex the shoulder against resistance. A positive test is when the patient feels pain in the bicipital groove. This test is specific but not sensitive for biceps tendonitis, SLAP lesions, and biceps rupture.

Yerguson’s test (Answer B) is performed with the elbow flexed to 90 degrees at the patient’s side. The examiner grasps the patient’s hand as if giving a hand shake and asks the patient to supinate against resistance. The examiner then palpates the patient’s proximal biceps. If the patient feels pain in the bicipital groove, the test is positive. This test, like Speed’s test, is specific but not sensitive for biceps tendonitis, SLAP lesions, and biceps rupture.

Tenderness to palpation over the intertubercular groove (Answer C) is indicative of biceps tendonitis.

A Popeye deformity (Answer E) occurs when the patient is asked to flex the elbow, and the biceps is seen to bunch up much more than the contralateral biceps. This is indicative of biceps tendon rupture, which can happen rarely in severe cases of biceps tendonitis.

If the above patient is clinically diagnosed with biceps tendonitis, what is the preferred initial management?

  1. Biceps tenotomy

  2. Biceps tenodesis

  3. Reconstruction of the transverse humeral ligament

  4. Physical therapy, rest, NSAIDs, cryotherapy, and corticosteroid injections

  5. Biceps repair

 

Discussion

The correct answer is (D). Like many shoulder injuries, first line treatment is conservative since it is better to treat noninvasively if there is a good chance the treatment is successful. Any type of surgery (Answers A, B, C, and E) carries with it significant risk and should be carried out only after failure of several weeks of conservative treatment. Injections can be given in the glenohumeral joint, since the biceps runs through it, or in the biceps tendon sheath in the intertubercular groove. When given in the groove, though, the injection should ideally be placed in the sheath around the tendon and not in the tendon itself.

Which of the following is not an indication for surgical intervention with long head of the biceps tendon pathology?

  1. “Hourglass” biceps tendon on arthroscopy

  2. 20% thickness tear

  3. Subscapularis tear with biceps tendon subluxation

  4. Isolated medial biceps tendon subluxation

  5. Inflamed “lipstick” biceps tendon on arthroscopy

 

Discussion

The correct answer is (B). Tears that are 25% thickness or less are usually not considered to need operative management. Those that are over 25% to 50% thickness are considered to need operative intervention. All the other choices are indications for surgical intervention, whether it be a tenotomy or a tenodesis.

An “hourglass” biceps tendon (Answer A) is one in which the intra-articular portion has hypertrophied to a point that it is not able to slide into the bicipital groove when the arm is flexed. When this occurs, the tendon bunches up in the joint and gets pinched between the humeral head and the glenoid, giving an appearance of an hourglass on arthroscopy when pinched. This causes a block to shoulder flexion of over 10 degrees. Surgical intervention will fix this problem.

A subscapularis tear with subluxation of the biceps tendon (Answer C), an isolated medial biceps tendon subluxation (Answer D), and an inflamed biceps tendon on arthroscopy (Answer E) all have high success rates when treated surgically. A “lipstick” biceps is so named because the inflammation causes the tendon to turn red, appearing as if there was lipstick applied to it (see Fig. 2–28).

 

 

 

Figure 2–28 Arthroscopic view of left inflamed biceps tendon (“lipstick biceps”). LHB, long head of the biceps; RI, rotator interval.

 

If the patient were elderly, what would be the preferred surgical intervention?

  1. Biceps tenotomy

  2. Biceps tenodesis

  3. Reconstruction of the transverse humeral ligament

  4. Physical therapy, rest, NSAIDs, cryotherapy, and corticosteroid injections

  5. Biceps repair

 

Discussion

The correct answer is (A). Both biceps tenotomy and tenodesis (Answer B) have high success in alleviating symptoms and in patient satisfaction. Biceps tenotomy has a higher incidence of a Popeye sign, cramping with extensive arm flexion, and pain in the bicipital groove. However, a change in arm aesthetics with a Popeye sign is less likely to matter to an elderly patient. The cramping with extensive arm flexion usually only occurs in patients less than 40 years old, and the pain in the bicipital groove does not translate into decreased function or patient satisfaction as

compared to tenodesis. These three factors, however, might make the increased difficulty of performing a tenodesis worth it for a younger patient and some active, healthy, elderly individuals.

Reconstruction of the transverse humeral ligament (Answer C) is not a surgery that is performed nor is a biceps repair (Answer E). Conservative treatment (Answer D) is not a surgical intervention, so it is an incorrect answer to this question.

If on physical examination there was a loss of deltoid contour visible at the anterior border or the middle deltoid, what pathology is likely present?

  1. Massive rotator cuff tear with deltoid rupture

  2. Isolated massive rotator cuff tear

  3. Anterior shoulder dislocation

  4. AC joint dislocation

  5. AC joint osteoarthritis

 

Discussion

The correct answer is (A). With a massive rotator cuff tear, there can be superior translation of the humeral head that causes the humeral head to articulate with the acromion around the insertion of the anterior part of the middle deltoid. The humeral head can then erode the deltoid insertion off of the acromion, causing deltoid rupture and a visible defect on physical examination. If this is not identified and repaired early, functional outcomes are usually terrible.

Which of the following is not a predictor for less-favorable outcomes after rotator cuff repair surgery?

  1. Diabetes

  2. Age

  3. Worker ’s compensation status

  4. Supraspinatus muscle atrophy

  5. Infraspinatus muscle fatty degeneration

 

Discussion

The correct answer is (A). No study to date has shown diabetes to be a predictor of less favorable outcomes after rotator cuff repair surgery. Increasing age (Answer B), having a worker’s compensation status (Answer C), supraspinatus muscle atrophy (Answer D), and infraspinatus muscle atrophy and fatty degeneration (Answer E) have all been shown to result in both reduced tendon-bone healing and

worse functional scores after rotator cuff repair surgery. Supraspinatus muscle fatty degeneration has been shown to have worse healing but has not been shown to result in lower clinical outcomes.

How long does it take for bone–tendon healing to occur?

  1. 0 to 2 weeks

  2. 2 to 4 weeks

  3. 4 to 8 weeks

  4. 8 to 12 weeks

  5. 12 to 16 weeks

 

Discussion

The correct answer is (D). The terminal tendon of the rotator cuff (RC) is relatively avascular, unable to heal itself, and gets more avascular as people age. Because of this, most vascularity that helps to heal the RC in a repair comes from the holes drilled in the greater tuberosity. This also means that the healing process is slow after repair and is likely to take between 8 and 12 weeks for the tendon to heal to the greater tuberosity, which requires limited passive and no active ROM postoperatively. For a repair with a latissimus dorsi transfer, which will be discussed below, the patient should be braced and immobilized for 6 weeks at 45 degrees abduction and 30 degrees external rotation.

 

Objectives: Did you learn...?

 

 

Clinically diagnose biceps tendonitis based on history and physical examination? Treat biceps tendonitis both conservatively and surgically?

 

Decide between biceps tenotomy and tenodesis?