Dr. Kevin Yip

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

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Treatment-Nonoperative

The initial treatment of bicipital tendinitis is conservative using the traditional methods of rest, ice, and nonsteroidal anti-inflammatory medications. As symptoms improve, range of motion exercises and strengthening can be added. The actual treatment is frequently directed more toward the treatment of underlying rotator cuff pathology. Subacromial injections or bicipital sheath injections may also be utilized. Caution should be exercised in injecting the bicipital sheath. Intratendinous injection should be avoided due to the risk of tendon rupture or atrophic changes.

Although DePalma reported on injection of the tendon directly, other authors recommend sheath injections with 74% good to excellent results. It can be difficult to inject directly into the bicipital sheath, and therefore intra-articular injections have been advocated by some  because the proximal portion of the tendon is directly accessible and some of the fluid can track down the bicipital groove.

We prefer an intra-articular injection using a standard posterior portal approach. The joint line is palpated and entered approximately 4 cm inferior and 4 cm medial to the posterolateral corner of the acromion. A 22-gauge 1.5-inch needle is aimed toward the coracoid and a pop is felt as the needle perforates the posterior capsule. This is the same direction as inserting a posterior cannula for glenohumeral arthroscopy.

Four ml of Betamethasone (6 mg per ml) and six ml of 0.5% lidocaine HCL are instilled into the glenohumeral joint. In addition to the rapid therapeutic effects of bupivicaine on the intra-articular portion of the biceps, its added volume aids in travel of the mix down the bicipital groove.

Injections of a corticosteroid should be limited to two or three injections due the risk of tendon rupture, fluid retention, and weight gain. The patient is seen back at monthly intervals for re-evaluation and possible repeat injection. If symptoms progress or the condition worsens, further work-up with MRI, ultrasound, or CT arthrogram may be indicated. If symptoms improve with initial conservative therapy, gradual increase in activities is allowed, still limiting any inciting activity until the patient is relatively symptom free.

If no other pathology is present, greater than 80% of patients can be expected to achieve good results with nonoperative treatment (65). If patients continue to have significant pain and further work-up including MRI is negative, other sources of pain must be considered such as cervical radiculopathy, instability, glenohumeral or acromioclavicular arthritis, coracoid impingement, adhesive capsulitis, lung conditions with referred pain such as Pancoast tumor (malignancy in the upper lobe of the lung), or medical conditions including cardiac or gallbladder referred pain.

Associated SLAP tears may be present, but little information regarding success rates with nonoperative treatment of SLAP lesions is available. The same conservative treatments may be employed, but many SLAP tears may ultimately require surgical intervention or may not be definitively diagnosed until arthroscopy is performed. The important subject of SLAP tears will be addressed elsewhere in this text.

Instability lesions of the biceps including subluxations or dislocations are frequently associated with rotator cuff tears. Treatment should be directed toward treatment of the rotator cuff tear and such treatment is frequently operative. Conservative treatment strategies should initially be employed but surgical intervention is often necessary. Ruptures of the LHB tendon typically do not require surgical intervention. Patients with proximal biceps ruptures regain function and have substantial pain relief. Many patients with pain before a biceps rupture will report pain relief once the rupture occurs.

An associated cosmetic defect may be present in approximately 21% of proximal biceps ruptures, and patients should be provided information regarding the minimal strength loss if surgical intervention is avoided. Mariani et al.It reported on 26 patients (27 shoulders) undergoing biceps tenodesis vs. 30 patients undergoing nonsurgical treatment. Residual arm pain was minimal in both groups. Biomechanical analysis showed a 21% loss of forearm supination strength and 8% loss of elbow flexion strength in the nonsurgical group.

The nonsurgical group had no weakness in pronation, elbow extension, or grip. The surgically treated patients had no loss of strength in elbow flexion, extension pronation, supination, or grip. Additionally, surgically treated patients returned to work later than nonsurgical patients, but 11 in the nonsurgical group were not able to return to full work capacity with weakness as their primary complaint. Only two patients in the surgically treated group could not return to full work capacity.

Warren tested 10 patients with chronic biceps ruptures and reported no loss of flexion strength and 10% loss of supination strength. Phillips et al.It used Cybex testing to compare nonoperative vs. operative intervention in 19 patients and found no significant difference in elbow flexion or supination strength.

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