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Biceps tendon tendonitis of the elbow

What is biceps tendon tendonitis?

Distal biceps tendon tendonitis is characterized by pain in the front of the elbow, presumably due to inflammation of the biceps tendon. However, most tendon conditions do not actually demonstrate true inflammatory tissue changes, and in fact, are considered “tendinosis,” a word reflecting pathologic changes within the tendon itself, usually from degeneration.

Most patients with anterior elbow pain have an element of tendinosis, usually at the insertion of the biceps tendon on the radial tuberosity (the site of attachment of the distal biceps tendon is on a small tubercle of the radius, or forearm bone). Disease or injury to the distal biceps tendon is important because it can cause symptoms and impairment with elbow flexion and when turning the forearm with the palm up (supination).

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How does biceps tendon tendonitis occur?

Tendonitis of the biceps is caused by strain from sudden increase in amount or intensity of activity or from overuse or repetitive elbow bending or wrist rotation, particularly with supination (when turning the palm up, such as when using a screwdriver).

What increases the risk?

  • Sports that involve heavy use of the elbow, such as gymnastics, weightlifting, bodybuilding or rock climbing
  • Heavy labor
  • Poor physical conditioning (strength and flexibility)
  • Inadequate warm-up before practice or play

What are the symptoms of biceps tendon tendonitis?

Pain or discomfort at the front of the elbow is the major symptom. Pain is exacerbated with elbow flexion (bending) and supination (turning the palm up).

How is biceps tendon tendonitis diagnosed?

A history of elbow pain in the antecubital fossa (front crease of the elbow) associated with tenderness along the course of the tendon towards its insertion on the radial tuberosity is an indicator of this condition, along with pain and/or weakness with supination of the forearm (turning the palm up) against resistance.

Are there any special tests?

  • X-rays
  • MRI is helpful in cases where there is sufficient tendonosis or partial tearing of the tendon, usually near or at its attachment site. Occasionally, fluid is seen around the tendon, an indirect indication of tendon involvement.

How is biceps tendonitis treated?

Initially, distal biceps tendonosis is treated non-operatively. This includes activity modification and avoidance of provocative activities, as well as pain medication and use of ice at the site of discomfort. Gentle stretching and subsequent strengthening have been advocated as helpful strategies to restore function as pain subsides.

Injections

Although cortisone injections have value in certain conditions, such as tennis elbow or rotator cuff tendon problems, there is no role for their use in treating distal biceps tendon problems. The distal biceps tendon is surrounded by important vessels and nerves, which preclude safe targeting.

Operative treatment is considered for those whose persistent symptoms have failed to respond to non-operative treatment. Surgery consists of an open incision of the anterior (front of) elbow and examination of the distal biceps tendon. In the vast majority of cases, degenerative changes with partial tearing are appreciated near the insertion site. The tendon is completed and released at the normal insertion site, the degenerative intervening tissue is debrided (surgically trimmed), and the tendon reinserted into its normal attachment site on the radius. A number of surgical techniques have been described for reattachment. The current most commonly performed procedure combines strong fixation with a minimally invasive approach to permit rapid restoration of normal use and return to activities.

What are the complications of treatment?

Possible complications of non-operative treatment include:

  • Persistent pain and impairment
  • Possible progression to complete tear

Possible complications of operative treatment include:

  • Surgical complications not specifically associated with exploration/reattachment, such as pain, bleeding, infection, nerve injury, stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity 
  • Complications specific to surgical exploration include the possibility that the tendon will in fact appear normal (rare), possible loss of motion (usually in pronation/supination or rotation of the forearm), and possible formation of bone in the soft tissues (known as heterotopic ossification) 
  • Repair failure, with re-rupture or detachment of the tendon, is very uncommon. 

When can you return to your sport/activity?

This condition may remit within a period of six weeks of non-operative treatment, though varies considerably depending upon the severity, hand dominance, activity level, etc.

Most patients can resume activities of daily living within two weeks of surgery (using current surgical techniques). However, tendon integration into the bone requires three months, which is the basis of avoiding any lifting or carrying anything heavier than a cup of coffee during this period. Strengthening begins at the three-month mark. The ability to return to previous level of activity depends upon a number of factors, but is within the three to six months range.

How can biceps tendon tendonitis be prevented?

Because most distal biceps tendon pathology is consequent to degeneration, prevention is not realistic. However, attention to symptoms early on may preclude progression or abrupt failure.

Activities that may facilitate prevention include:

  • Avoid provocative activities that precipitate or exacerbate symptoms
  • Perform appropriate warm up and stretch before practice or competition
  • Allow of time for adequate rest and recovery between practices and competition
  • Maintain of appropriate conditioning:
    • Elbow flexibility
    • Muscle strength and endurance
    • Cardiovascular fitness
  • Use of proper technique
 
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