What is the treatment for bicep tendinosis with interstitial tearing?

Treatment for Bicep Tendinosis with Interstitial Tearing

The treatment for bicep tendinosis with interstitial tearing should begin with conservative management including relative rest, NSAIDs, physical therapy with eccentric exercises, and possibly corticosteroid injections, with surgical intervention considered only if conservative measures fail after 3-6 months. 1, 2, 3

Initial Conservative Management

First-Line Treatments

• Relative rest and activity modification: Reduce activities that exacerbate pain and avoid movements that stress the affected biceps tendon 1
• Ice therapy: Apply ice through a wet towel for 10-minute periods to reduce pain and swelling 1
• NSAIDs: Use oral or topical NSAIDs as first-line medication for pain and inflammation 1, 2
  • Options include ibuprofen, naproxen, or topical NSAIDs for localized pain
  • Acetaminophen (up to 4g/day) if NSAIDs are contraindicated

Physical Therapy

• Eccentric strengthening exercises: These have proven beneficial in tendinopathies by stimulating collagen production and guiding normal alignment of newly formed collagen fibers 1
• Stretching exercises: Generally helpful and widely accepted for tendinopathies 1
• Progressive rehabilitation: Gradually increase load on the tendon to promote healing and functional recovery

Advanced Conservative Interventions

Corticosteroid Injections

• Consider ultrasound-guided corticosteroid injection into the biceps tendon sheath if initial conservative measures fail after 4-6 weeks 2, 3
• Studies show good results in 12 out of 21 cases of distal biceps tendinopathy with steroid injections 3
• Caution: Use judiciously as corticosteroids may inhibit healing and reduce tensile strength of the tendon 1
• Dosage for elbow/biceps area typically ranges from 10-40 mg of methylprednisolone 4

Supportive Measures

• Orthotics and braces: Can help reinforce, unload, and protect the tendon during activity 1
• Therapeutic ultrasound: May decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1

Monitoring and Progression

• Reassess pain and function every 4-6 weeks
• If symptoms persist beyond 3 months despite appropriate conservative management, consider advanced imaging and surgical consultation
• MRI or ultrasound can help visualize the extent of tendon damage and guide further treatment decisions 2

Surgical Management

• Surgery should be considered if:
  • Conservative measures fail after 3-6 months 2, 3
  • There is severe damage to the biceps tendon 2
  • Partial tears >50% of the tendon diameter are present 5
• Surgical options include:
  • Debridement for partial tears <50% 5
  • Complete division and repair for tears >50% 5

Treatment Algorithm Based on Severity

1. Mild tendinosis (minimal tearing):

   • NSAIDs, ice, relative rest
   • Physical therapy with eccentric exercises
   • Reassess after 4-6 weeks

2. Moderate tendinosis with interstitial tearing:

   • All treatments for mild cases
   • Consider ultrasound-guided corticosteroid injection if no improvement after 4-6 weeks
   • Bracing or orthotics to unload the tendon
   • Reassess after 8-12 weeks

3. Severe tendinosis with significant tearing (>50%):

   • Trial of conservative management for 3 months
   • If no improvement, surgical consultation for potential repair

Common Pitfalls and Caveats

• Misdiagnosis: Biceps tendinopathy often coexists with rotator cuff tears or SLAP lesions; ensure proper diagnosis with appropriate imaging 2
• Overuse of corticosteroids: Limit to 2-3 injections with 4-6 weeks between injections to avoid tendon weakening 1, 4
• Delayed surgical referral: Persistent symptoms beyond 3-6 months of appropriate conservative management should prompt surgical consultation 2, 3
• Inadequate physical therapy: Proper eccentric loading is essential for tendon healing; ensure exercises are performed correctly and progressively 1

Research shows that conservative treatment of biceps tendinopathy yields good results in approximately 76% of cases (16 out of 21 patients in one study) 3, making it the appropriate first-line approach for most patients with bicep tendinosis with interstitial tearing.