What is the initial management for biceps tendinosis?

Initial Management for Biceps Tendinosis

The initial management for biceps tendinosis should focus on conservative measures including relative rest, ice therapy, NSAIDs, and eccentric strengthening exercises for 3-6 months before considering more invasive interventions. 1, 2

First-Line Conservative Management

• Relative Rest: Decrease repetitive loading of the damaged tendon while avoiding complete immobilization to prevent muscular atrophy and deconditioning 1
• Ice Therapy: Apply ice through a wet towel for 10-minute periods to provide short-term pain relief, reduce swelling, and blunt inflammatory response 1, 2
• NSAIDs: Both oral and topical NSAIDs effectively relieve pain, with topical formulations preferred due to reduced risk of gastrointestinal side effects 1, 2
• Eccentric Strengthening Exercises: Stimulate collagen production and guide normal alignment of newly formed collagen fibers 1, 2
• Stretching Exercises: Generally helpful and widely accepted for tendon rehabilitation 1, 2

Physical Examination Findings

• Deep, throbbing ache in the anterior shoulder is the typical complaint 3
• Bicipital groove point tenderness with the arm in 10 degrees of internal rotation is the most common isolated clinical finding 3
• Pain is often exacerbated by repetitive overhead motion of the arm 3
• Palpation typically elicits well-localized tenderness similar in quality and location to pain experienced during activity 1

Diagnostic Considerations

• Plain radiographs are beneficial as initial imaging to rule out other causes of elbow pain 1
• Ultrasonography is preferred for visualizing the overall tendon 3
• MRI or CT arthrography is preferred for visualizing intra-articular tendon and related pathology 3

Second-Line Treatments

• Braces: Tennis elbow bands can help reinforce, unload, and protect tendons during activity, though evidence for their effectiveness is limited 1, 2
• Corticosteroid Injections: May provide better acute pain relief than NSAIDs but do not alter long-term outcomes 1
  • Caution: Direct injection into the tendon substance should be avoided as it may inhibit healing and reduce tensile strength, potentially predisposing to rupture 1, 2
• Therapeutic Ultrasonography: May decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1, 2
• Extracorporeal Shock Wave Therapy (ESWT): Appears safe and effective but requires further research 1, 2

Surgical Management

• Surgery should be considered only if conservative measures fail after 3-6 months of well-managed treatment 1, 2, 3
• Surgical options include biceps tenotomy or tenodesis depending on patient age, activity level, and other factors 4, 5, 6
• Both tenotomy and tenodesis have been shown to be effective options with no substantial differences in functional scores or patient satisfaction 5, 6

Important Considerations

• Most patients with overuse tendinopathies (approximately 80%) fully recover within 3-6 months with appropriate conservative treatment 2
• Technique modification for athletes and manual laborers is important to minimize repetitive stresses placed on tendons 1, 2
• Biceps tendinitis and tendinosis are commonly accompanied by rotator cuff tears or SLAP lesions, which may require additional treatment 3, 7