After the corticosteroid solution is injected, remove the syringe and reattach the mL syringe with lidocaine and sodium bicarbonate. Slowly withdraw the needle while injecting the remaining lidocaine and sodium bicarbonate. This will flush any remaining corticosteroid solution out of the needle, lessening the chance that any remaining solution might cause skin atrophy or depigmentation.
An alternative technique is to combine the lidocaine with sodium bicarbonate and corticosteroid solution in the same syringe to avoid changing syringes. Apply the plastic bandage. Instruct the patient to keep it on for eight to 10 hours and watch for signs of infection, which may include erythema, increased pain, pus at the injection site, and a low-grade fever of Reexamine the patient after 15 to 20 minutes.
Pain relief indicates a diagnosis of biceps tendinitis. Confirm the diagnosis by performing the Yergason test. It should be negative. A patient may also report pain relief if there is instability or subluxation of the biceps tendon. If the shoulder is still painful, consider problems with the rotator cuff, adhesive capsulitis, calcific tendinitis, or subacromial bursitis. Information from references 19 , 26 , and Radiologic evaluation to diagnose biceps tendinitis or tendinosis should begin with radiography of the shoulder to rule out primary causes of impingement Table 3 5 , 10 , 12 , 14 , 32 — Negative results on radiography should be followed by ultrasonography of the shoulder, which is the best method by which to extra-articularly visualize the biceps tendon.
Suspected accompanying anatomic lesions may be seen with magnetic resonance imaging MRI. If the patient demonstrates shoulder weakness and pain with an intact rotator cuff and labrum, electromyography should be performed to rule out a neuropathy. CT arthrography shows biceps tendon subluxations, ruptures, dislocations, and SLAP lesions 14 MRI arthrography is preferable for diagnosing biceps lesions and SLAP lesions 14 because the agreement between MRI and arthroscopy for biceps lesions is only 37 percent and 60 percent for rotator cuff lesions.
Invasive Filling of the biceps tendon sheath is unreliable 40 Sharp images of the tendon may be lost 41 Ionizing radiation. Bicipital groove view radiography Shows the width and medial wall angle of the bicipital groove, spurs in the groove, and supertubercular bone spur or ridge Inexpensive Does not show possible intra-articular disorders of the labrum soft tissue injuries Excellent evaluation of the superior labral complex and biceps tendon Partial tears of the biceps tendon are more difficult to detect than complete ruptures Expensive 5 Poorly correlated with arthroscopy Radiography anteroposterior views of the shoulder and acromioclavicular joint, lateral axilla, outlet view, and ALVIS view Rules out shoulder fracture and strains or dislocations of the acromioclavicular joint and arthritis of the glenohumeral and acromioclavicular joint Inexpensive Cystic changes in the lesser tuberosity are a sign of biceps tendinosis or upper subscapularis tear 14 In impingement syndrome, a subacromial spur is usually visible on the outlet and ALVIS views.
Relatively inexpensive May be used for patients with metallic implants Dynamic Widely available No ionizing radiation Offers better spatial resolution than MRI and may be used for local anesthetic or corticosteroid injections into the biceps tendon sheath 14 , 33 — 39 An overall sensitivity of 49 percent and a specificity of 97 percent.
Requires an experienced operator High frequency array transducer Blind areas Difficult to scan patients who are obese 14 , 33 — Information from references 5 , 10 , 12 , 14 , and 32 through Biceps tendinitis or tendinosis may respond to analgesia with nonsteroidal anti-inflammatory drugs NSAIDs , acetaminophen to avoid side effects from NSAIDs , ice, rest from overhead activity, or physical therapy.
The patient may begin exercises after the shoulder is pain-free. The goal of stretching is to regain a balanced range of motion without stiffness or pain in any position. The stretching program should include the hamstrings and low back as well. A throwing program may be started after the rotator cuff, scapular rotators, and prime humeral movers i. The same program applies to the nonathlete, but with less emphasis on throwing.
Surgery should be considered if conservative measures fail after three months. Structures causing primary and secondary impingement may be removed, and the biceps tendon may be repaired if necessary. Debridement should be performed if less than 50 percent of the biceps tendon is torn.
A biceps tenotomy may be performed to remove the ruptured biceps tendon from the glenohumeral joint, and tenodesis may be avoided without significant loss of arm function. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Catherine A. Reprints are not available from the author. Biceps tendinitis and subluxation. Clin Sports Med. Kibler WB. Scapular involvement in impingement: signs and symptoms. Instr Course Lect.
Abrams JS. Special shoulder problems in the throwing athlete: pathology, diagnosis, and nonoperative management. Special considerations in the athletic throwing shoulder.
Orthop Clin North Am. Evaluation and treatment of biceps tendon pathology. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am. Habermeyer P, Walch G.
The biceps tendon and rotator cuff disease. In: Burkhead WZ Jr, ed. Rotator Cuff Disorders. Philadelphia, Pa. Anatomy, histology, and vascularity of the glenoid labrum. An anatomical study. Superior labrum, anterior-posterior lesions and biceps injuries: diagnostic and treatment considerations. Prim Care. The painful shoulder: Part II. Intrinsic disorders and impingement syndrome. Am Fam Physician. Neer CS II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report.
Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg. Disorders of the superior labrum: review and treatment guidelines. Clin Orthop Relat Res. Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br. Paynter KS. Impingement lesions. Impingement syndrome in athletes. Am J Sports Med.
Berg D, Worzala K, eds. Atlas of Adult Physical Diagnosis. Bicep tears at the elbow occur much more commonly in men rather than women. Weakness after a tear at the elbow persists because the tendon retracts due to the muscular contraction. This results in the tendon scarring into a non-anatomic position resulting in permanent weakness.
Because of this loss in power in turning the palm up, most patents will opt for surgical management. Surgical management can restore power both for elbow flexion and turning the palm up. The bicep muscle is one of few muscles that span two joints. The muscle originates above the shoulder and inserts into the tuberosity of the radius. The biceps muscle has two tendons that attach the muscle to the shoulder and one tendon that attaches at the elbow.
Most bicep tears are complete. Although there is some controversy, the current trend in partial tears is toward surgical management. These partial tears are thought to progress to complete tears. In complete tears, the tendon ruptures away from the radial tuberosity and retracts. This gap will not fill in and the tendon remains permanently detached from the radial tuberosity.
Although certain medications may weaken tendons, the typical cause of a distal bicep tear is eccentric force—lifting a heavy object. Males are typically affected rather than females and most men are over 30 years of age.
Most patients present with pain and deformity of the elbow. Most patients have significant bruising of the arm. Patients may report that they felt the tendon tear at the time of injury. A right elbow distal bicep tear demonstrating bruising and swelling. Also note the bicep appears to be closer to the shoulder than in a normal elbow due to the contraction of the muscle.
After taking a complete history, your orthopedic surgeon sill evaluate your arm. An examination centers on range of motion of the shoulder and elbow—also the status of the associated nerves and arteries. The surgeon will note the deformities present and signs of bruising. The surgeon may palpate to determine if there is a gap in the distal bicep tendon. In some cases the surgeon may order additional testing. Most people consider its function to be a flexor of the elbow but in reality, other muscles tend to do this and its main function is to turn the forearm into an upward position the position which you place the hand in to receive money, also known as supination.
The most common tendon tear is at the long head of biceps proximally in the shoulder while the second most common region is distally where it attaches to the elbow. Muscle belly tears can also occur. The least common is that of coracoid tendon tears, which commonly involves a fragment of bone pulling away with it at the site a coracoid fracture. We will restrict our discussion to the two most common sites, the long head of biceps or the distal biceps tendon.
Tears of the long head of the biceps, at the shoulder, are very common. They especially occur with age, as the tendon degenerates. It will often present with several months of increasing pain around the shoulder before a sudden onset of more pain, bruising and then swelling. Often there is the development of more prominent biceps but which appears distally further down the arm to where the normal biceps muscle appears. People are often concerned by the lump thinking it is something sinister, but it is the bunched up muscle moving further down the arm.
Whilst proximal bicep tendon tears often result in a cosmetic abnormality, there is no loss of physical function. There is a large amount of evidence that weakness is not an issue; there is no evidence that patients who have suffered a long biceps tendon tears are weaker.
In fact, often after the tear, the pain the patient was experiencing before the tear has reduced. With this, the strength improves. One option for treatment is to treat the initial pain, reassure the patient and let the arm settle. The alternative is to repair the biceps tendon.
Please note that a long head of biceps tendon repair is not a true repair as it does not involve reattaching it to where it came from which is through the shoulder joint and at the top of the socket. Instead, the biceps tendon is tensioned and re-attached to either soft tissue or bone below the shoulder joint, bypassing the shoulder joint. Surgery may be performed if the patient is unwilling to accept the cosmetic abnormality, or if there are other facts that may warrant surgical intervention.
In these cases, consideration will be undertaken to tenodesing retensioning the long head of biceps.
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