Biceps Tendinitis Treatment

Activity modification

• While the tendon is acutely inflamed and still in the early recovery period, it is important to prevent activities that further stress the tendon. This is accomplished by avoiding repetitive overhead lifting or reaching and using a neutral forearm grip during exercise
• To avoid overuse of the tendon, patients should utilize cross training and vary their workouts with both pushing and pulling activities so the shoulder is balanced. For example, patients who do biceps curls but do not focus on latissimus or rhomboid exercises can easily overtrain the biceps
• For better ergonomics, utilizing an adjustable workstation while working or placing heavier items at shoulder level or below can avoid excessive stress on the biceps. An example of this is placing a heavy crock pot not above shoulder level but at or below shoulder level so the biceps does not become inflamed.

Reducing inflammation

There are three main ways to calm the inflammation in the biceps tendon

Oral anti-inflammatories:

• An oral medication can be very useful when taken for a short duration of time at the appropriate dosage to calm the inflammation down. If medically tolerated, oral NSAIDs (non-steroidal anti-inflammatory drugs) taken consistently for about 10 to 14 days can significantly calm the inflammation within the tendon sheath.
• Another oral option is a Medrol dose pack or short steroid taper that also can work to reduce acute inflammation. However, steroids, even when taken for a short period of time, can have side effects such as irritability or increased sugar levels so caution should be taken when utilizing either of these options.

Topical:

• Another way to reduce inflammation in the tendon is the use of a topical anti-inflammatory like Voltaren gel. This gel when applied over the biceps tendon sheath area can provide a local anti-inflammatory effect that has the added benefit of not requiring ingestion of any medication.
• In addition, the application of either an ice pack or cooled gel pack to the anterior shoulder for 15-20 minutes at a time, 2-3 times daily, with a barrier between the ice and the skin can be effective in calming down acute inflammation of the biceps tendon.

Injection:

• If the inflammation supersedes what can be controlled by either oral or topical medications, then one can consider an ultrasound-guided injection of a small amount of steroid into the bicipital sheath. This calms down persistent inflammation and does not violate the tendon itself, but is injected into the sheath to help bathe the tendon and calm the inflammation down.
• This injection serves two purposes. It is therapeutic as it helps the patient calm the initial pain but is also diagnostic in that it helps quantify to both the patient and provider how much of the overall shoulder pain is coming from the biceps tendon itself. This is helpful as shoulder pain is often multifactorial with multiple pain generators.

Physical therapy

a. Once the inflammation in the biceps sheath has been sufficiently reduced, initiating physical therapy is essential in order to normalize both shoulder mechanics and to improve the health of the biceps tendon.

b. Modalities that are important here include:

• Scapular stabilization and postural correction to avoid a protracted and down-and-out shoulder blade that can cause pinching of the biceps tendon.
• Rotator cuff and parascapular strengthening, especially of the subscapularis, is important to restore a stable shoulder throughout a range of motion.
• If there is posterior capsule tightness present with a loss of internal rotation, gentle stretching of the posterior capsule using a cross-body adduction or sleeper stretch is useful.
• The hallmark of therapy regarding any tendinitis is gradual eccentric strengthening progression of the biceps tendon. These exercises take a short, contracted tendon to an elongated, more normally strengthened tendon that is not inflamed.

c. Forearm straps or shoulder supports are optional to provide short-term symptom relief but are not as important as undergoing a thoughtful therapy protocol under the supervision of a therapist with a transition to a home exercise program.

Indications

The surgical indications to manage biceps tendinitis include

• Persistent pain that lasts more than three months despite a well designed and compliant non-operative treatment protocol
• MRI evidence of a persistently symptomatic partial tear within the long head of the biceps or instability of the biceps tendon with subluxation of the tendon out of the groove. Instability of the tendon is often seen when there is an associated subscapularis tear
• Concomitant pathology that requires surgical treatment such as associated rotator cuff tear or labral tear where the biceps tendinopathy can be treated at the same time.

Surgical options

There are three main surgical options to treat biceps tendinitis.

• Biceps debridement: A simple debridement of the biceps tendon can be performed if less than half the tendon is significantly inflamed or irritated. An arthroscopic shaver is used to gently clean this irritated portion of the tendon thereby leaving the rest of the tendon alone
• Biceps tenotomy:
  • A tenotomy involves completely releasing the biceps tendon from its origination on the superior labrum and letting it scar further down the humerus.
  • This method of tenotomizing the tendon is often chosen for elderly lower-demand patients as it has a quick recovery and low risk of any complications.
  • The downsides include cramping within the muscle belly that resolves after a couple months and a tenotomy can cause a cosmetic Popeye deformity with bunching up of the biceps muscle belly. Despite these minor setbacks, there is truly no long-term functional weakness after a tenotomy due to preservation of the short head of the biceps and the brachialis.
• Biceps tenodesis:
  • A tenodesis involves both releasing the biceps from its origin on the superior labrum and then reattaching it down further on the humerus to maintain the contour and strength of the biceps.
  • This is more often used in our younger active patient population or those who will not tolerate a cosmetic deformity.
  • Biceps tenodesis can be performed arthroscopically or open with a small incision and the open procedure has the advantage of removing the biceps from the groove which can be a source of groove pain due to nerve fibers within the groove itself.

Rehabilitation

• For isolated biceps surgery assuming there is no other shoulder pathology being addressed, the standard rehabilitation after surgery includes a sling for 1 to 2 weeks with early passive motion progressing to active assisted motion by 2 weeks after surgery.
• If a tenodesis is performed, patients should avoid resisted elbow flexion and supination for 6 weeks from the time of surgery, gradually strengthen the tendon at 8 to 12 weeks, and expectation of a full recovery from a tenodesis at the 3 to 4 month post-operative mark.

With proper evaluation and a tailored treatment plan, most patients with biceps tendinitis return to full activity without pain.