Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Clinical Evaluation-Physical Findings

Distinguishing anterior shoulder pain caused by biceps tendon disorders as opposed to subacromial impingement can be difficult, as these two entities usually co-exist. Although there are some exam maneuvers, which attempt to isolate the biceps tendon, there is still a fair amount of overlap and the definitive diagnosis of isolated biceps tendon pathology is extremely difficult based on history and physical exam alone. Often selective injections are helpful in differentiating the etiology of the pain.

The hallmark of biceps tendon related pathology is point tenderness in the bicipital groove. Without this finding it is extremely unlikely the LHB is involved in the patient’s symptoms. The bicipital groove is best palpated approximately three inches below the acromion with the arm in 10 degrees of internal rotation . As the arm is internally and externally rotated, the pain should move with the arm.

This is distinct from subacromial bursitis where the pain location remains relatively constant despite the position of the arm. Burkhead et al. It reports this “tenderness in motion” sign was quite specific for biceps tendon disorders. In the situation in which it is unclear whether the pain is secondary to the LHB or to possible impingement/bursitis, selective injections of these areas can help make the diagnosis.

There are several provocative tests that can be helpful in the diagnosis of LHB pathology; however, the sensitivity/specificity of these tests are questionable. These tests are intended for the diagnosis of LHB pathology. Tests for the diagnosis of SLAP lesions are covered elsewhere in this textbook.

  • Speed’s test—With the elbow in extension, the patient flexes the shoulder against resistance from the examiner. Pain in the bicipital groove is considered positive.
  • Yergason test—The patient attempts to supinate the wrist against resistance (with the elbow flexed at the side). Pain in the bicipital groove is considered positive.
  • Bear Hug test—This test was developed by Barth et al. Because these lesions are almost always associated with LHB instability, it is a good test for LHB pathology. The patient places the open palm of the affected extremity on the contralateral shoulder. In so doing, the ipsilateral elbow is held well anterior to the plane of the patient’s body.As the examiner tries to lift the hand off the shoulder (resisted internal rotation), the patient tries to keep the palm on the shoulder. Weakness (in comparison to the contralateral side) is a positive test and indicative of a tear of the upper subscapularis (and thereby likely LHB instability). In general, the examiner should not be able to lift the hand off the contralateral shoulder unless there is tearing of the upper subscapularis, in which case there is usually concomitant subluxation of the biceps tendon.
  • Napoleon test -This test also attempts to assess the integrity of the subscapularis for the reasons noted in the previous bullet point. The patient pushes on the abdomen with the palm of the affected extremity and tries to keep the wrist completely straight. If the patient is unable to keep the wrist straight but rather flexes the wrist to perform the test, this is considered a positive or intermediate test and suggestive of a subscapularis tear.
  • Belly-Press test —This test is similar to the Napoleon test in that the patient places the palm on the abdomen with the wrist held straight. The physician then tries to pull the hand off of the abdomen. If the physician is able to pull the hand off easily, this is considered a positive test and suggestive of a subscapularis tear.
  • Lift-off tes—This is the fourth test to assess subscapularis integrity. The patient places the back of the hand of the affected extremity on the ipsilateral buttock. The examiner then lifts the hand posteriorly and asks the patient to hold it in that position. Weakness or inability to lift the hand off the lower back is considered positive and suggestive of a subscapularis tear.

Other tests have been described, such as the Ludington test , biceps instability test , and the deAnguin’s test; however, we do not utilize these tests and have therefore not described them. The described tests can be useful in assisting the clinician with the diagnosis of biceps tendon disorders.

As noted previously, however, the sensitivity/specificity of most of these tests has not been examined. The exceptions include the Speed test, which Bennett  determined to be 90% sensitive for shoulder pain, but only 13% specific for bicipital pathology. Its positive predictive value was 23% while its negative predictive value was 83%. The Bear Hug test was determined to have a sensitivity of 60% and specificity of 92% for tears of the upper subscapularis .

Findings associated with complete rupture of the LHB are usually much more obvious. Examination reveals an alteration of the contour of the biceps such that a portion of the biceps feels (and appears) “balled up” at the mid arm level. This is termed the “Popeye” muscle. Rupture of the LHB is also often accompanied by ecchymosis, which migrates down the anterior surface of the arm.

Given the intimate relationship between biceps tendon pathology and concomitant subacromial impingement and/or rotator cuff tear it is important to examine the remainder of the shoulder in this patient population. Specific tests for range of motion, impingement, rotator cuff integrity, and instability should be performed.

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