Long Head of the Biceps Injection for Bicipital Tendinitis

Indications and Clinical Considerations

The musculotendinous unit of the shoulder joint is susceptible to developing tendinitis for several reasons. First, the joint is subjected to a wide range of motions that are often repetitive. Second, the space in which the musculotendinous unit functions is restricted by the coracoacromial arch, making impingement a likely possibility with extreme movements of the joint. Third, the blood supply to the musculotendinous unit is poor, making healing of microtrauma more difficult. All of these factors can contribute to tendinitis of 1 or more of the tendons of the shoulder joint. Calcium deposits and bone spurs around the tendon may occur if the inflammation continues, making subsequent treatment more difficult ( Fig. 40.1 ). Tendinitis of the biceps tendon frequently coexists with bursitis of the associated bursae of the shoulder joint, creating additional pain and functional disability.

The tendons of the long and short heads of the biceps, either alone or together, are particularly prone to the development of tendinitis, which is known as bicipital tendinitis. The cause of this syndrome is usually, at least in part, impingement on the biceps tendons at the coracoacromial arch. Bicipital tendinitis onset is usually acute, occurring after overuse or misuse of the shoulder joint. Inciting factors may include activities such as trying to start a recalcitrant lawn mower, practicing an overhead tennis serve, or overaggressive follow-through when driving golf balls. The pain of bicipital tendinitis is constant, severe, and localized in the anterior shoulder over the bicipital groove. A “catching” sensation also may accompany the pain. Significant sleep disturbance is often reported. The patient may attempt to splint the inflamed tendons by internal rotation of the humerus, which moves the biceps tendon from beneath the coracoacromial arch. Patients with bicipital tendinitis exhibit a positive Yergason test, which is production of pain on active supination of the forearm against resistance with the elbow flexed at a right angle ( Fig. 40.2 ). Bursitis often accompanies bicipital tendinitis.

In addition to the previously described pain, patients with bicipital tendinitis often experience a gradual decrease in functional ability with decreasing shoulder range of motion, making simple everyday tasks, such as hair combing, fastening a bra, or reaching overhead, difficult. With continued disuse, muscle wasting may occur, and a frozen shoulder may develop.

Plain radiographs are indicated for all patients with shoulder pain. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and ultrasound imaging of the shoulder are indicated if a tendon rupture is suspected and to help identify tendinitis ( Fig. 40.3 ). The injection technique presented later serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The biceps tendon, along with conjoined tendons of the rotator cuff, aids in the stability of the shoulder joint. The biceps muscle, which is innervated by the musculocutaneous nerve, supinates the forearm and flexes the elbow joint. The biceps muscle has a long and a short head ( Fig. 40.4 ). The long head has its origin in the supraglenoid tubercle of the scapula; the short head has its origin from the tip of the coracoid process of the scapula. The long head exits the shoulder joint via the bicipital groove, where it is susceptible to tendinitis. It is joined by the short head in the middle portion of the upper arm. The insertion of the biceps muscle is into the posterior portion of the radial tuberosity. The biceps muscle and tendons are susceptible to trauma and to wear and tear from overuse and misuse, as mentioned previously. If the damage becomes severe enough, the tendon of the long head of the biceps can rupture, leaving the patient with a telltale “Popeye” biceps ( Fig. 40.5 ). This deformity can be accentuated by having the patient perform the Ludington maneuver, in which the patient places his or her hands behind the head and flexes the biceps muscle.