New York State Medical Treatment Guidelines for
Bicipital Tendon Disorders in workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Bicipital Tendon Disorders.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Bicipital Tendon Disorders of Shoulder Injury

Bicipital tendon disorders include the following: 1) primary bicipital tendonitis, which is extremely uncommon; 2) secondary bicipital tendinitis, which is typically linked to rotator cuff tendinitis or impingement syndrome (refer to the appropriate diagnosis subsections); 3) subluxation of the biceps tendon, which happens when the transverse intertubercular ligament is dysfunctional and there are significant rotator cuff tears; and 4) acute disruption. When assessing a bicipital tendon injury, an evaluation of the elbow may be necessary.

History and Mechanism of Injury of Bicipital Tendon Disorders

• Mechanism of Injury: Bicipital tendon problems may cause pain and/or achiness that follows repetitive shoulder motion or blunt shoulder trauma.Long-term above-the-shoulder activities, as well as frequent shoulder flexion, external rotation, and abduction, may cause secondary bicipital tendinitis. The biceps tendon can get injured as a result of acute trauma to the shoulder girdle.
• Biceps tendon disorders may coexist with various shoulder pathologies such as subdeltoid bursitis, AC joint separation, rotator cuff injury, shoulder instability, and scapulothoracic dyskinesis. Work that causes the biceps muscle to contract may aggravate symptoms or perhaps cause them. Other activities that aren’t necessarily work-related could make symptoms worse.
• Aching, burning, and/or stabbing shoulder discomfort are possible symptoms; this area of the shoulder girdle is typically affected. Above-the-shoulder exercises and those that specifically work the biceps (shoulder flexion, elbow flexion, and forearm supination) aggravate the symptoms. Rest brings about relief.
  Patients may experience nocturnal symptoms that keep them up at night during the acute stages of inflammation, pain and weakness in the shoulder during activities, a repeated snapping phenomenon with a subluxing tendon, immediate sharp pain and tenderness along the long head of the biceps following a sudden trauma that would raise suspicions of acute disruption of the tendon, and/or with predominant pain at the shoulder.

Physical Findings of Bicipital Tendon Disorders

Physical Findings may include:

• If the tendon’s continuity has been compromised (biceps tendon), rupture), a shoulder examination would show biceps bunching, a malformation;
• The bicipital tendon is painful to the touch along its length;
• Biceps tendon activation and pain at the extremities of flexion and abduction

Tests that are provocative may include:

• Yegerson’s sign: discomfort with resisted forearm supination;
• Speed’s Test: discomfort with resisted shoulder flexion (elbow extended and forearm supinated); or
• By placing the hands behind the head and contracting the biceps, one can perform the Ludington’s Test, which causes the shoulders to externally rotate and abduct.

Laboratory Tests of Bicipital Tendon Disorders

Laboratory Tests of Bicipital Tendon Disorders are recommended when a systemic illness or disease is suspected in a subset of patients.

Diagnostic Testing Procedures X-Ray

Diagnostic Testing Procedures X-Ray are recommended clinically appropriate in a subset of patients.

Plain x-rays consist of:

• When the rotator cuff is torn, the anterior/posterior (AP) view shows elevation of the humeral head as a sign of its absence;
• If there is anterior or posterior dislocation or the existence of a defect in the humeral head (a Hill-Sachs lesion), it can be determined using a lateral view in the plane of the scapula or an axillary view.
• If there is a spur on the anterior/inferior surface of the acromion and/or the far end of the clavicle, it can be seen in a 30 degree caudally angulated AP view;
• Outlet view indicates whether an acromion with a downward tip exists.

Sonography, MRI or arthrography (Adjunctive testing)

Sonography, MRI or arthrography (Adjunctive testing) are recommended clinically appropriate in a subset of patients.

Indications: should be taken into account when shoulder pain is unresponsive to four to six weeks of conservative non-operative treatment and the diagnosis is difficult to make using conventional radiography techniques.

Non-Operative Treatment Procedures

Non-Operative Treatment Procedures are recommended as prescribed by a physician.

• Rest, followed by treatments including heat therapy, immobilisation, changing one’s job or workstation, and manual therapy, can be beneficial.
• Narcotics are typically not indicated; instead, medications such nonsteroidal anti-inflammatories and analgesics are recommended.
  Interventions in physical therapy and rehabilitation should involve a gradual improvement in range of motion. A strengthening programme should be started once the patient has improved their range of motion and pain management, at which point a return to modified or limited duty might be contemplated. When full motion has been restored by 8–11 weeks, resumption to full duties should be anticipated.

Soft tissue injections (biceps tendon insertion) With steroids

Indications: If the patient NYS WCB MTG – Shoulder Injury 27 responds favourably to a diagnostic injection of anaesthetic, the procedure might be therapeutic. If the patient NYS WCB MTG – Shoulder Injury 27 responds favourably to a diagnostic injection of anaesthetic, the procedure might be therapeutic.

Frequency: In most cases, one or two injections are sufficient. It is advised to wait at least three weeks between injections. Local anaesthetics take immediate impact, but corticosteroids take three days to take effect. Maximum duration: Three injections at the same place per year is the maximum allowed.

Operative Procedures – e.g Arthroscopic biceps tenodesis or tenotomy for subluxing and/or inflammatory/tearing biceps tendon, or subluxing biceps tendon with partial or complete subscapularis tearing

Operative Procedures – e.g Arthroscopic biceps tenodesis or tenotomy for subluxing and/or inflammatory/tearing biceps tendon, or subluxing biceps tendon with partial or complete subscapularis tearing are recommended clinically appropriate in a subset of patients.

Bicipital Tendinitis:
Indications: Prior to probable surgery, conservative management must address flexibility and strength abnormalities. When proper conservative therapy for 12 weeks has proven unsuccessful, surgical options would be examined. An acromioplasty might be required because the biceps tendon could continue to be irritated by impingement, particularly if plain x-rays show the existence of an obstructing osteophyte.

Subluxing Bicipital Tendon:
Indications: It is not frequently advised to surgically fix the bicipital tendon. The vast majority of the time, effective rehabilitation techniques result in the best possible outcomes, and before undergoing surgery, suitable non-surgical treatments should be used to their fullest extent.

Acute Disruption of the Bicipital Tendon:
Indications: Treatment for full thickness ruptures of the distal biceps tendon has been proven to be more successful with surgery than with conservative measures.

Post-Operative Procedure
A tailored rehabilitation programme based on discussion between the doctor, the surgeon, and the therapist would be included. In order to facilitate the greatest possible medical improvement, rehabilitation spanning 6–12 weeks is required (MMI).

What our office can do if you have Bicipital Tendon Disorders

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