1. In the name of GOD

2. Biceps tendinitis

3. Functional anatomy
As its name implies, the biceps has 2 proximal heads with a common distal insertion onto the radius. The long head of the biceps merges with the short head of the biceps to form the body of the biceps brachii muscle. This muscle is a powerful supinator and flexor of the forearm. The long head biceps tendon lies in the bicipital groove of the humerus between the greater and lesser tuberosities and angles 90° inward at the upper end of the groove, crossing the humeral head to insert at the upper edge of the glenoid labrum and supraglenoid tubercle. The long head of the biceps tendon helps to stabilize the humeral head, especially during abduction and external rotation

4. Anatomy
The tendon is exposed on the anterior shoulder as it passes through the humeral bicipital groove and inserts onto the superior aspect of the labrum of the glenohumeral joint

5. Biceps tendinitis
Bicipital tendinitis, or biceps tendinitis, is an inflammatory process of the long head of the biceps tendon and is a common cause of shoulder pain due to its position and function.

6. Causes
1.The long head of the biceps tendon passes down the bicipital groove in a fibrous sheath between the subscapularis and supraspinatus tendons. This relationship causes the biceps tendon to undergo degenerative and attritional changes that are associated with rotator cuff disease because the biceps tendon shares the associated inflammatory process within the suprahumeral joint..

7. 2.Full humeral head abduction places the attachment area of the rotator cuff and biceps tendon under the acromion. External rotation of the humerus at or above the horizontal level compresses these suprahumeral structures into the anterior acromion. Repeated irritation leads to inflammation, edema, microscopic tearing, and degenerative changes..

8. 3.In younger athletes, relative instability due to hyperlaxity may cause similar inflammatory changes on the biceps tendon due to excessive motion of the humeral head. such as baseball pitchers, swimmers, gymnasts, racquet sport enthusiasts (eg, tennis players), and rowing/kayak athletes 4.Labral tears may disrupt the biceps anchor, resulting in dysfunction and causing pain.

9. 5. The transverse humeral ligament holds the biceps tendon long head within the bicipital groove. Injuries and disruption of the ligament can lead to subluxation and medial dislocation of the biceps tendon. Local edema and calcifications can physically displace the biceps tendon from the bicipital groove, resulting in subluxation. An osteochondroma in the bicipital groove has been reported as a cause of bicipital tendinitis in a baseball player by physical displacement and subluxation.

10. Presentation
Patients typically complain of achy anterior shoulder pain, which is exacerbated by lifting or elevated pushing or pulling. A typical complaint is pain with overhead activity or with lifting heavy objects. Pain may be localized in a vertical line along the anterior humerus, which worsens with movement. Often, however, the location of the pain is vague, and symptoms may improve with rest. An occasional snapping sound or sensation in the shouldeR

11. Physical exam
1.Local tenderness is usually present over the bicipital groove, which is typically located 3 inches below the anterior acromion. The tenderness may be localized best with the arm in 10 º of external rotation. 2.Flexion of the elbow against resistance aggravates the patient's pain.

12. Passive abduction of the arm in an arc maneuver may elicit pain Speed test: The patient complains of anterior shoulder pain with flexion of the shoulder against resistance, while the elbow is extended and the forearm is supinated.

13. Yergason test: The patient complains of pain and tenderness over the bicipital groove with forearm supination against resistance, with the elbow flexed and the shoulder in adduction. Popping of subluxation of the biceps tendon may be demonstrated with this maneuver.

14. Work up
Laboratory Studies Laboratory tests are usually not indicated in cases of bicipital tendinitis, except when considering systemic diseases in the differential diagnosis or when excluding the possibility of neoplasm

15. Imaging Studies
1.radiographic.
*Standard shoulder radiographs are generally not helpful or necessary in cases of isolated bicipital tendinitis.
*Plain radiographs with bicipital groove views may demonstrate calcifications in the groove; however, calcifications rarely alter treatment. Radiographic studies of the neck and elbow may be necessary to exclude referred shoulder pain from these locations.

16. *Radiographs are indicated in cases that are not isolated, do not respond to treatment, or in patients in which there is the clinical suspicion of or a history of neoplastic disease.* * Subacromial spurring is often seen in impingement syndrome and is most visible on the outlet and anteroposterior impingement syndrome radiographic views.

17. 3. Ultrasound and arthrography 4. Arthroscopy
2.MRI
This imaging study can demonstrate the entire course of the long head of the biceps tendon. However, MRI is expensive and not cost effective as a routine imaging test for bicipital lesions
3. Ultrasound and arthrography
4. Arthroscopy
Arthroscopy may be useful in evaluating chronic shoulder pain

18. Treatment Nonsurgical Treatment
Biceps tendonitis is typically first treated with simple methods.
Rest. The first step toward recovery is to avoid overhead activity.
Ice. Apply cold packs for 20 minutes at a time, several times a day, to keep swelling down. Do not apply ice directly to the skin.

19. Nonsteroidal anti-inflammatory medicines
Nonsteroidal anti-inflammatory medicines. Drugs like ibuprofen and naproxen reduce pain and swelling.

20. Steroid injections. Steroids, like cortisone, are very effective anti-inflammatory medicines. Injecting steroids into the tendon can relieve pain. Your doctor will use these cautiously. In rare circumstances, steroid injections can further weaken the already injured tendon, causing it to tear.
Local anesthetics.
Local anesthetics block the generation of conduction impulses in a nerve, thereby preventing the transmission of pain Bupivacaine (Sensorcaine, Marcaine) .
Physical therapy. Specific stretching and strengthening exercises will restore range of motion and strengthen your shoulder.

21. Surgical Treatment
If your condition does not improve with nonsurgical treatment, your doctor may suggest surgery. Surgery may also be necessary if you have other shoulder problems.
Surgery for biceps tendonitis is usually performed arthroscopically. During arthroscopy, your doctor makes small incisions around your shoulder. He or she then inserts a small camera and miniature instruments through the incisions. This allows your doctor to assess the condition of the biceps tendon as well as other structures in the shoulder.

22. Repair. In many cases, the biceps tendon can be repaired and strengthened where it attaches to the shoulder socket (glenoid).
Biceps tenodesis. In some cases, the damaged section of the biceps is removed, and the remaining tendon is reattached to the upper arm bone (humerus). This procedure is called a biceps tenodesis. Removing the painful part of the biceps usually resolves symptoms and restores normal function.
Depending on your situation, your surgeon may choose to do this procedure arthroscopically or through an open incision.

24. Tenotomy. In severe cases, the long head of the biceps tendon may be so damaged that it is not possible to repair or tenodese it. Your surgeon may simply elect to release the damaged biceps tendon from its attachment. This is called a biceps tenotomy. This option is the least invasive, but may result in a Popeye bulge in the arm

25. Surgical complications.
Complications are rare with these types of arthroscopic procedures. Infection, bleeding, stiffness and other problems are much less common than open surgical procedures
Rehabilitation.
After surgery, your doctor will prescribe a rehabilitation plan based on the procedures performed. You may wear a sling for a few weeks to protect the tendon repair..

26. You should have immediate use of your hand for daily activities — writing, using a computer, eating, or washing. Your doctor may restrict certain activities to allow the repaired tendon to heal. It is important to follow your doctor's directions after surgery to avoid damage to your repaired biceps. Your doctor will soon start you on therapeutic exercises. Flexibility exercises will improve range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.

27. Surgical outcome
. Most patients have good results. They typically regain full range of motion and are able to move their arms without pain. People who play very high-demand overhead sports occasionally need to limit these activities after surgery.

28. Prevention
1.warm-ups before exercise. 2.Use of strengthening exercise. 3.Avoidance of painful activities. 4.Use of proper biomechanics. 5.Increased attention should be made for those athletes at high risk of bicipital tendinitis, such as baseball pitchers…

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