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 at the coracoacromial arch is the most common cause, or at least a contributing factor, in cases of bicipital tendinitis.

• In most cases, the onset of bicipital tendinitis is sudden and occurs after the shoulder joint has been overused or used improperly.

  • This can be caused by trying to start a lawn mower that is difficult to start, practicing an overhead tennis serve, or performing an overly aggressive follow-through when driving golf balls, among other activities.

• Both the muscle and the tendons that attach to the biceps are vulnerable to damage and wear and tear.

• The tendon of the long head of the biceps can rupture if the damage is severe enough, leaving the patient with the characteristic "Popeye" biceps (named after the cartoon character).

• The patient can exaggerate the appearance of this deformity by performing the Ludington maneuver, which involves placing his or her hands behind the patient's head and flexing the biceps muscle.

SIGNS AND SYMPTOMS

• The pain that is caused by bicipital tendinitis is consistent and severe, and it is located in the front of the shoulder, directly above the bicipital groove.

• It's possible that the pain will be accompanied by a catching sensation.

• It is frequently reported that significant sleep disturbances occurred.

• Internal rotation of the humerus, which moves the biceps tendon from beneath the coracoacromial arch, is a technique that the patient may use in an effort to splint the tendons that have become inflamed.

• Patients who suffer from bicipital tendinitis have a positive result on Yergason's test, which indicates that they experience pain when actively supinating the forearm against resistance while the elbow is flexed at a right angle.

• Bursitis and tendinitis of the bicipital region frequently occur together.

• Patients who suffer from bicipital tendinitis, in addition to experiencing pain, frequently experience a gradual reduction in functional ability as a result of a decreasing shoulder range of motion.

• This decrease in shoulder range of motion makes it difficult to perform simple everyday tasks such as combing one's hair, fastening a brassiere, and reaching overhead.

• Muscle atrophy and the development of a frozen shoulder are both potential outcomes of prolonged periods of inactivity.

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. Imaging of the shoulder using magnetic resonance and ultrasound is recommended when a rotator cuff tear is suspected and when further shoulder pathology delineation is required.

• In certain patients, bicipital tendinitis can be diagnosed and treated more effectively with the assistance of arthroscopy.

• The injection technique that will be described later can be utilized both as a diagnostic tool and a treatment strategy.

DIFFERENTIAL DIAGNOSIS

• The diagnosis of bicipital tendinitis is typically uncomplicated 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, tendinitis of the bicipital region can be confused with a partial tear of the rotator cuff.

• 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.

• The pain that comes before the appearance of vesicular lesions on the skin caused by acute herpes zoster can be mistaken for the pain caused by bicipital tendinitis.

TREATMENT

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

• Both of these types of medications are anti-inflammatory medications.

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

• Patients who do not respond to these treatment modalities may benefit from an injection that combines a steroid and a local anesthetic.

• When administering an injection for bicipital tendinitis, the patient is positioned in the supine position with the affected 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.

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.