The guidelines established by the New York State Workers Compensation Board are designed to aid healthcare professionals in providing appropriate treatment for bicipital tendon disorders.
Crafted for medical practitioners, these Workers Compensation Board guidelines offer assistance in determining the suitable approach for individuals with bicipital tendon disorders.
It’s crucial to note that these guidelines do not replace clinical judgment or professional experience. The final decision on treatment for bicipital tendon disorders should be a collaborative one, involving the patient and their healthcare provider in consultation.
Bicipital Tendon Disorders Overview:
Primary Bicipital Tendonitis: Primary bicipital tendonitis is exceptionally rare.
Secondary Bicipital Tendinitis: 2) Secondary bicipital tendinitis is generally associated with rotator cuff tendinitis or impingement syndrome (refer to the appropriate diagnosis subsections).
Subluxation of the Biceps Tendon: 3) Subluxation of the biceps tendon occurs with dysfunction of the transverse intertubercular ligament and massive rotator cuff tears.
Acute Disruption of the Tendon: 4) Acute disruption of the tendon can result from an acute distractive force or transection of the tendon due to direct trauma.
Elbow Evaluation in Bicipital Tendon Injury: Evaluation of the elbow may be necessary when assessing bicipital tendon injury.
History and Mechanism of Injury:
Mechanism of Injury: Bicipital tendon disorders may manifest as pain and/or achiness resulting from repetitive shoulder use or blunt trauma. Secondary bicipital tendinitis can be linked to prolonged above-the-shoulder activities, repeated shoulder flexion, external rotation, and abduction. Acute trauma to the biceps tendon in the shoulder girdle can also lead to biceps tendon injury.
Associated Disorders: Disorders of the biceps tendon may coexist with scapulothoracic dyskinesis, rotator cuff injury, AC joint separation, subdeltoid bursitis, shoulder instability, or other shoulder pathologies. Symptoms may worsen with work activating the biceps muscle and may also be exacerbated by non-work-related activities.
Symptoms: Symptoms may include aching, burning, or stabbing pain in the shoulder, particularly in the anterior medial portion of the shoulder girdle. Symptoms worsen with above-the-shoulder and biceps-engaging activities, with relief occurring during rest. Nocturnal symptoms may interfere with sleep during acute inflammation. Additional symptoms include pain and weakness during shoulder activities, snapping phenomenon with tendon subluxation, and sharp pain along the long head of the biceps after sudden trauma. Predominant shoulder pain may have referral patterns extending into cervical or distal structures like the arm, elbow, forearm, and wrist.
Physical Findings:
Deformity in Rupture: If tendon continuity is lost (biceps tendon rupture), shoulder inspection may reveal deformity, with the biceps bunching.
Tenderness and Pain: Palpation may demonstrate tenderness along the bicipital tendon’s course. Pain may be present at the end range of flexion and abduction, as well as during biceps tendon activation.
Provocative Testing: Provocative testing methods may include:
- Yegerson’s sign: Pain with resisted supination of the forearm.
- Speed’s Test: Pain with resisted flexion of the shoulder (elbow extended and forearm supinated).
- Ludington’s Test: Pain with contraction of the biceps (hands placed behind the head, shoulders in abduction and external rotation).
Identification by Radiographic Techniques: Bicipital tendon disorders can be identified through standard radiographic techniques.
Non-Operative Treatment Procedures:
Recommendations: Non-operative treatment procedures are recommended based on clinical indications.
Rest and Thermal Therapy:
- Benefit can be achieved through rest, followed by procedures such as thermal therapy, immobilization, alteration of occupation and/or workstation, and manual therapy.
Medications:
- Medications, including nonsteroidal anti-inflammatories and analgesics, are indicated. Narcotics are not typically recommended.
Rehabilitation Interventions:
- Physical medicine and rehabilitation interventions should focus on a progressive increase in range of motion. With improved motion and pain control, a strengthening program should be initiated, and consideration of return to modified/limited duty may be appropriate. By 8-11 weeks, with full motion restored, a return to full duty is anticipated.
Soft Tissue Injections with Steroids:
- Soft tissue injections (biceps tendon insertion) with steroids are indicated if the patient responded positively to a diagnostic injection of an anesthetic. Steroid injections directly into the tendons are not advised. Usually, one or two injections are sufficient, with a minimum three-week interval and a maximum of three injections annually to the same site.
Operative Procedures:
Recommendations: Operative procedures, such as arthroscopic biceps tenodesis or tenotomy, are recommended for select patients based on clinical indications.
Bicipital Tendinitis:
- For bicipital tendinitis, surgical consideration follows 12 weeks of failed conservative care addressing flexibility and strength imbalances. Acromioplasty may be necessary if impingement of the biceps tendon persists, especially with evidence of an obstructing osteophyte on x-rays.
Subluxing Bicipital Tendon:
- Surgical stabilization of the subluxing bicipital tendon is not commonly indicated. Successful rehabilitation procedures and non-surgical measures should be maximized before considering surgery.
Acute Disruption of the Bicipital Tendon:
- Surgery is more effective than conservative care for full-thickness ruptures of the distal biceps tendon.
Post-Operative Procedures:
Post-operative procedures for bicipital tendon disorders involve an individualized rehabilitation program based on communication among the physician, surgeon, and therapist. Rehabilitation, lasting 6-12 weeks, is necessary for achieving maximum medical improvement (MMI).
