Clinical Evaluation

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The evaluation of biceps disorders requires a detailed history and physical examination as symptoms can be vague. It is important to determine when the onset of pain occurred and how it has progressed. Was there a traumatic event? Are the symptoms activity related? The level of athletic participation can play an integral role in the diagnosis and treatment of biceps disorder. Some patients will describe a popping or clicking sensation, but this has to be differentiated from other shoulder disorders. It is difficult to differentiate bicipital groove pain from impingement and anterior cuff pain. With disorders specific to the biceps tendon, pain often radiates down to the muscle belly. Patients can also give a long history of anterior shoulder pain and popping that spontaneously resolved after a specific incident requiring elbow flexion. This is a classic story of a patient with chronic biceps tendonitis who ruptured his or her biceps tendon. Instability of the biceps tendon can sometimes be difficult to assess clinically. Often the patient will describe a history of painful snapping when moving from an abducted externally rotated position to internal rotation, a motion that is replicated frequently in overhead athletes.

On physical examination, the patient should be inspected for symmetry of both upper extremities. A ruptured long head of the biceps can result in the classic "Popeye" deformity in which the muscle of the long head of the biceps is retracted distally leaving a characteristic bulge in the distal arm (Fig. 24-2). Strength and range of motion of both shoulders should be documented. Changes in range of motion are variable and are often in conjunction with rotator cuff disease. Impingement as well as stability testing must be included in the examination. Direct palpation of the biceps tendon can sometimes be difficult. The bicipital groove faces anteriorly when the arm is in slight internal rotation. Pain consistent with biceps tendonopathy will move laterally as the arm is externally rotated. Biceps pain can sometimes be elicited with shoulder extension and internal rotation.

Due to the difficulty in isolating biceps tendonopathy, diagnostic tests designed specific to the biceps tendon have been described to help localize shoulder pain. The clinical effective ness of these tests, however, is examiner dependent, and many clinicians find them nonspecific.19 Speed's test is attempted elevation of the arm against resistance with the elbow extended and the forearm supinated. A positive test is elicited when there is pain in the anterior aspect of the shoulder, and this is suggestive of biceps tendonopathy. The Yergason test is resisted forearm supination with the elbow flexed at 90 degrees. The test is positive when there is pain in the biceps.

Differential injections may also be useful in diagnosing biceps disorders. An injection into the subacromial space should have no effect on biceps pain unless a full-thickness rotator cuff tear is present. Conversely, assuming no other intra-articular pathology, an intra-articular injection of local anesthetic should resolve any symptoms caused by the biceps tendon. A more accurate diagnosis can be obtained from an injection of local anesthetic directly into the sheath of the biceps tendon. It is important, however, to avoid an intertendinous injection. A helpful injection technique is to place the patient supine on the examining table with the elbow flexed 90 degrees and internally rotated 10 degrees. In this position, the bicipital groove can on occasion be palpated. When the local anesthetic is introduced, there should be no resistance to flow if the needle is correctly placed in the sheath. In large patients with excessive soft tissue overlying the anterior aspect of the shoulder, ultrasonography-guided injections are sometimes required.

Patients with biceps instability will usually present with a history of shoulder pain associated with popping and catching. One method for testing biceps stability is to position the arm in

Figure 24-2 Patient demonstrating a characteristic Popeye deformity (A). Compare to the contralateral normal side (B).

Figure 24-2 Patient demonstrating a characteristic Popeye deformity (A). Compare to the contralateral normal side (B).

abduction and external rotation while palpating the bicipital groove. In cases of instability, as the arm approaches 90 degrees of abduction and external rotation, a palpable clunk will be appreciated at the anterior edge of the acromion.20 In the evaluation for biceps stability, an essential aspect of the physical examination is to assess the integrity of the subscapularis tendon with the Gerber lift-off test.21 This test is performed by bringing the patient's arm into maximum internal rotation behind the back, with the hand away from the back. The patient's ability to maintain the position after the examiner releases the hand is indicative of an intact subscapularis tendon. The combination of a detailed history and complete physical examination is essential in the workup of biceps tendon disorders and should help narrow the differential diagnosis.

Plain film radiographs should always be the first set of images obtained in the evaluation of shoulder pathology. The standard three views of the shoulder: a true anteroposterior, scapular outlet, and axillary views are the minimum requirements to rule out any associated conditions. The plain films will help evaluate the glenohumeral joint for any degenerative changes, acromion morphology, and evidence of acromioclavicular (AC) joint arthrosis, but plain films will rarely be able to provide any information that is specific to the biceps tendon. Radiographs may offer hints about other osseous abnormalities such as a HillSachs lesion or a bony Bankart lesion. In cases in which there is a suspected abnormality of the bicipital groove, a specific view has been developed by Cone et al.1 This view is obtained by placing the radiographic cassette at the apex of the shoulder with the arm externally rotated. The beam is then aimed along the medial axis of the long axis of the humerus, allowing visualization of any osteophytes or narrowing of the bicipital groove. Ultrasonography has the benefit of being noninvasive and the ability to detect tendon size as well as the presence of fluid in the tendon sheath. Although it is user dependent, studies have shown ultrasonography to be effective in the evaluation of biceps tendonopathy as well as concurrent rotator cuff disease.22

Due to its rapidly advancing technology, magnetic resonance imaging has become the gold standard for visualizing the surrounding soft-tissue anatomy of the shoulder. Magnetic resonance imaging has the ability to evaluate for rotator cuff pathology, including intrasubstance signal changes that are consistent with tendonosis.23 Biceps subluxations are best seen on oblique and sagittal views. Edema associated with tendonitis is visible on the T2-weighted images. Tendon ruptures are easy to visualize and are represented by a discontinuity of the tendon along its course.

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