- •
Although certain provocative maneuvers can help to guide the decision making process, they are nonspecific and imperfect.
- •
Biceps tendon pain may be more difficult to discern in the absence of a frank tear or changes in signal intensity as perceived by MRI.
- •
Studies using MRI or arthroscopy as the gold standard may miss this diagnosis.
How Accurate Are We in Detecting Biceps Tendinopathy?
Section snippets
Key points
Introduction: nature of the problem
Anterior shoulder pain can result from several different pathologies, including rotator cuff tears, rotator cuff tendinitis, subacromial bursitis, impingement (subacromial and subcoracoid), acromioclavicular joint arthritis, and anterior labral tears, as well as biceps tendinopathy, instability, and tendon tears. Advanced imaging studies including MRI can help to delineate many of these pathologies with the exception of the biceps tendon, which is frequently missed or misdiagnosed. A strong
What Do We Know About Biceps Tendinopathy?
In the author’s experience, the clinical symptoms of biceps tendinopathy are anterior shoulder pain or pain down “the side of the arm” that occurs with rotation of the shoulder, such as when patients reach in the backseat of their car, tuck in their pants in, or fasten their bra. The patients often have pain at night that wakes them from sleep, especially if they are side sleepers (which often requires external rotation and adduction). The bicipital groove is tender on palpation and many, but
Studies evaluating the efficacy of MRI
In addition to clinical evaluation, imaging studies including noncontrast MRI have been evaluated as a diagnostic modality for biceps pathology. Dubrow and colleagues5 evaluated the efficacy of noncontrast MRI in detecting biceps tendinopathy in conjunction with diagnostic arthroscopy. Sixty-six patients suspected of having biceps tendinopathy, partial or complete biceps tendon tears, biceps instability, or SLAP tear were evaluated using noncontrast MRI.5 All patients had previously failed
Discussion
Although certain provocative maneuvers can help guide our decision making process, they are nonspecific and imperfect. Furthermore, biceps tendon pain as it relates to tendinopathy may be more difficult to discern in the absence of a frank tear or changes in signal intensity as perceived by magnetic resonance imaging. Studies that use MRI or arthroscopy as the gold standard may therefore miss this diagnosis.
Histologic analysis of the biceps tendon demonstrates microscopic changes in the
Summary
Biceps tendon pain in the absence of biceps tendon tears is associated with microscopic changes consistent with tendinopathy. In the author’s opinion, biceps tendon pain is best recognized by utilizing a combination of clinical symptoms of pain with rotation, physical examination with tenderness over the bicipital groove and, finally, ultrasound-guided injection into the bicipital groove to confirm the diagnosis. Tendinopathy is often missed by MRI.
References (13)
- et al.
A prospective, double-blind comparison of magnetic resonance imaging and arthroscopy in the evaluation of patients presenting with shoulder pain
J Shoulder Elbow Surg
(2004) - et al.
The incidence of pathologic changes of the long head of the biceps tendon
J Shoulder Elbow Surg
(2000) - et al.
The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology
J Shoulder Elbow Surg
(2006) Specificity of the speed’s test: arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove
Arthroscopy
(1998)- et al.
Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and slap lesions: comparison with arthroscopic findings
Arthroscopy
(2004) - et al.
Tendinopathy of the long head of the biceps tendon: histopathologic analysis of the extra-articular biceps tendon and tenosynovium
Open Access J Sports Med
(2015)
Cited by (13)
Editorial Commentary: Black Mirror: Reviving the Art of the Physical Exam
2019, Arthroscopy - Journal of Arthroscopic and Related SurgerySubpectoral Biceps Tenodesis: Interference Screw and Cortical Button Fixation
2017, Arthroscopy TechniquesSubpectoral Biceps Tenodesis for Tenosynovitis of the Long Head of the Biceps in Active Patients Younger Than 45 Years Old
2017, Arthroscopy - Journal of Arthroscopic and Related SurgeryCitation Excerpt :Especially in the context of tenosynovitis, the subpectoral technique may have an advantage over other more proximal techniques due to the possibility of ongoing tenosynovitis, within and distal to the bicipital groove.45,48,54 Surgeons must have a high degree of clinical suspicion when arthroscopically evaluating the LHB tendon in a patient with chronic anterior shoulder pain since more distal aspects of the tendon cannot be properly visualized.55-57 This study evaluated the outcomes of subpectoral BT for patients with isolated LHB tenosynovitis.
MRI, arthroscopic and histopathologic cross correlation in biceps tenodesis specimens with emphasis on the normal appearing proximal tendon
2019, Clinical ImagingCitation Excerpt :Numerous reports comparing arthroscopy and MRI have demonstrated poor concordance with arthroscopic findings in the detection of proximal biceps pathology including poor to moderate sensitivity for inflammation, partial-thickness tears, and rupture [6,12,16,20]. The correlation of arthroscopic and histologic findings in the abnormal LHBT has identified histologic features including varying degrees of chronic inflammation, fibrosis, mucinous degeneration, vascular congestion, dystrophic calcification and acute inflammation [10,13,17]. Histological and molecular analysis post-tenotomy has demonstrated the LHBT exhibits increased proteoglycan and collagen type III [9] which may in part explain the signal changes observed in cases of biceps tendinopathy.
Anterior and Lateral Shoulder Disorders
2022, Clinical Guide to Musculoskeletal Medicine: A Multidisciplinary ApproachBiceps tendon
2021, Tendinopathy: From Basic Science to Clinical Management
R. Gobezie receives royalties from Arthrex Inc.