Biceps tendinopathy - TM

Question 1

What is biceps tendinopathy?

Answer 1

• Variety of pathological changes within tendon
• = painful, swollen, structurally weaker and increase risk of rupture

Question 2

Where can this occur?

Answer 2

• Proximal or distal bicep
• In younger active people esp sports with repetitive flexion and older individuals with degenerative changes

Question 3

Clinical features

Answer 3

• Pain
• Worsened with stressing the tendon
• Alleviated by rest and ice
• Weakness of flexion and supination
• Stiffness
• Tenderness over tendon
• Can get disuse atrophy if pain has made them stop using limb

Question 4

Special tests for biceps tendinopathy

Answer 4

• Speed test - proximal biceps tendon
• Yergasons test - distal

Question 5

Speed test

Answer 5

• Elbows extended
• Forearms supinated
• Forward flex shoulders against examiners resistance

Question 6

Yergasons test

Answer 6

• Elbows flexed to 90 degrees
• Forearm pronated
• Actively supinate against resistance

Question 7

Investigations biceps tendinopathy

Answer 7

• Clinical diagnosis largely
• Can do bloods, CRP and plain radiographs to exclude other diagnosis
• Specialist imaging eg USS and MRI cab be used to show thickened (and inflamed for MRI) tendons

Question 8

Management biceps tendinopathy

Answer 8

• Conservatively
• NSAIDs for analgesia
• Ice
• Physiotherapy
• USS guided steroid injections can be used if not responsive to initial therapy

Question 9

Surgery for biceps tendinopathy

Answer 9

• RARE - for decompression
• Arthroscopic tenodesis (tendon severed and reattached) OR
• Tenotomy (division of tendon)

Question 10

Complication of BT

Answer 10

• Rupture of biceps tendon

Question 11

Biceps tendon rupture

Answer 11

• Can be complete or partial tear
• Often occur following sudeen forced extension of flexed elbow (distal)

Question 12

RF biceps tendon rupture

Answer 12

• Previous biceps tendinopathy
• Steroid use
• Smoking
• CKD
• Fluroquinolone abx eg Ciprofloxacin

Question 13

Clinical features of rupture

Answer 13

• Sudden onset of pain and weakness - flexion at elbow remain due to brachialis and supinator
• Swelling and bruising
• Feeling of ‘pop’
• As proximal belly retracts, can get ‘reverse popeye sign’

Question 14

Test for distal tendon rupture

Answer 14

Hook test
* Elbow flexed at 90 degrees
* Fully supinated
* Examiner attempts to hook index finger underneath lateral edge of biceps tendon - cannot be done if ruptured

Question 15

Investigations for rupture

Answer 15

• Clinically
• Confirm via USS
• Also help surgeon localise distal end of biceps tendon which can retract proximally
• If USS inconclusive but suspect still - MRI

Question 16

Management biceps rupture

Answer 16

• Flexion and supination can still occur but weakened - not all cases need surgical management
• BUT fatigueable and weak muscles = problem
• For lower demand pts - conservative with analgesia and physio
• Others - surgery

Question 17

Surgical management biceps rupture

Answer 17

• Anterior single incision OR
• Dual incision technique
• Form bone tunnel in radius and reinsert ruptured tendon end
• Should occur within few weeks of injury otherwise tendon retracts and scars

Antecubital fossa incision or antecubital and posterolateral elbow

Question 18

Complications surgery for biceps rupture

Answer 18

Injury to:
* Lateral antebrachial cutaenous nerve
* Posterior interosseous nerve
* Radial nerve (rare)

Question 19

Proximal vs distal biceps rupture

Answer 19

• Proximal of long head more common (glenoid), shoulder pain, popeye sign
• Distal less common, reverse popeye sign