What is the treatment for bicipital tenosynovitis?

Treatment of Bicipital Tenosynovitis

The most effective treatment for bicipital tenosynovitis consists of a comprehensive rehabilitation program including NSAIDs for pain relief, eccentric strengthening exercises, and functional support, while limiting corticosteroid injections to cases that don't respond to initial therapy.

Initial Conservative Management (0-4 weeks)

Pain Control

• NSAIDs are first-line for pain management:
  • Ibuprofen 1.2g daily (can increase to 2.4g daily if needed)
  • Naproxen 500mg twice daily
  • Can be combined with acetaminophen (up to 4g daily) for enhanced pain relief 1

Physical Therapy

• Protected range of motion exercises
• Ice application to reduce inflammation
• Avoid activities that exacerbate symptoms, particularly repetitive overhead motion 2
• Rest from aggravating activities

Intermediate Phase (4-8 weeks)

Progressive Rehabilitation

• Eccentric strengthening exercises targeting the biceps tendon
• Gradual increase in range of motion
• Functional support with a brace may be helpful 1

Adjunctive Therapies

If symptoms persist after 4-6 weeks of conservative management:

• Corticosteroid injections into the biceps tendon sheath:

  • Provides short-term relief but doesn't change long-term outcomes
  • Limit to 2-3 injections with 4-6 weeks between injections 1, 2
  • Can be both therapeutic and diagnostic 2

• Radial extracorporeal shock wave therapy (rESWT):

  • Emerging evidence shows significant improvement in pain and function
  • Protocol: 1500 pulses, 8 Hz, 3 bars, once weekly for four weeks 3
  • Studies show sustained reduction in pain scores from baseline (5.67) to one month (2.58), three months (1.83), and 12 months (1.43) 3

Advanced Phase (8-12 weeks)

Occupation-Specific Training

• Functional exercises specific to patient's activities
• Gradual return to normal activities 1

Evaluation for Surgical Intervention

• Consider surgical referral if no improvement after 3-6 months of well-managed conservative treatment 1, 2
• Surgical options include tenodesis of the biceps tendon in severe cases 2

Diagnostic Considerations

Imaging

• Ultrasonography is preferred for visualizing the overall tendon
• MRI or CT arthrography is preferred for visualizing intra-articular tendon and related pathology
• Important to rule out associated conditions such as rotator cuff tears or SLAP lesions 2

Follow-up Protocol

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement 1

Clinical Pearls and Pitfalls

Common Pitfalls

• Failing to identify associated shoulder pathologies (rotator cuff tears, SLAP lesions)
• Overreliance on corticosteroid injections without proper rehabilitation
• Prolonged immobilization, which can lead to stiffness and muscle atrophy

Important Considerations

• Bicipital tendinitis is often accompanied by other shoulder pathologies
• The most common isolated clinical finding is bicipital groove point tenderness with the arm in 10 degrees of internal rotation 2
• Return to full activity should only be permitted when the patient demonstrates complete resolution of pain, full range of motion, and strength symmetry >90% compared to the uninjured side 1