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A general overview as to why overuse injuries occur and the symptoms of biceps tendinopathy
By: Linsay Sunderland

This article is a clinical practitioner's detailed response to the article Biceps Tendon Ruptures Common in Big Bench Pressers

Overuse injury is one of the most often-seen conditions in primary care. It is one of the most common etiologies of shoulder pain, and is the third most prevalent musculoskeletal complaint. Overuse injuries of the upper extremity can have an especially negative impact on patients' work, leisure, and activities of daily living.

Overuse injury results from repetitive trauma (usually microtrauma) that eventually overwhelms the tissue's ability to repair itself. When abnormal stress is applied to normal tissue, the structural response depends on the affected tissue. Wolff's law states that bone will respond in proportion to, and in the direction of, the applied stress. With muscle, however, hypertrophy of the existing fibers will result, whereas tendons will respond with increased numbers of collagen fibers and increased cross-linking.

There are 4 pathophysiologic stages after an initial injury: inflammation, proliferation, maturation, and fibrosis.

  • The inflammatory response, with the classic hallmarks of pain, swelling, erythema, and warmth, lasts 48 hours to 1 week.

  • The proliferative, a poorly organized collagen is produced; this stage lasts 1 to 3 weeks.

  • Maturation, which can last 6 to 12 weeks, involves organized restructuring of the tissue and cross-linking of the collagen fibers.

  • With a continuous or repeated inflammatory response and inadequate time for healing between insults, fibrosis occurs.

    Fibrotic tissue is not as strong as healthy, normal tissue. In tendon sheaths, its formation can lead to stenosing tenosynovitis; in musculotendinous tissue, the pathologic change is angiofibrotic hyperplasia, which may eventually lead to degeneration and even rupture of the involved musculotendinous unit. As the body ages, muscles and tendons degenerate without initial insult, and this can further predispose the involved area to injury.

    Tendinopathy encompasses the spectrum of pathologic conditions from acute tendinitis to tendinosis to frank tear. In primary care, overuse injuries are often more chronic by history; the repetitive cycle of injury without complete repair between insults can lead to structural changes within the musculotendinous unit. Imagine the collagen fibers of tendons looking like a bowl of spaghetti, unorganized and in disarray, rather than in their usual orderly linear arrangement with cross-linking.

    Tendinitis may be a misnomer in many cases of overuse injury; tendinosis or tendinopathy may be the more appropriate description. The pathophysiologic distinction is important in understanding and managing overuse injuries.

    Biceps tendinopathy describes pain and tenderness in the region of the biceps tendon. The biceps musculotendinous junction is particularly susceptible to overuse injuries, especially in individuals performing repetitive lifting activities. This condition is often diagnosed incorrectly and confused with rotator cuff disease.

    Biceps tendinopathy is rarely seen in isolation. It coexists with other pathologies of the shoulder, including rotator cuff tendinopathy and tears, shoulder instability, and imbalances of the rotator cuff. Historically, all disorders of the biceps tendon have been termed biceps tendinitis. Recent evidence suggests that degenerative changes in the tendon occur without inflammation. In acute cases, anti-inflammatory pathology may still be a valid explanation of biceps tendon pain.

    Tendinitis describes inflammation of the tendon and the paratendon. This is usually caused by chronic overload, leading to microscopic tears in the tendon, which triggers an inflammatory response.

    Peritendinitis is the inflammation of the paratendon or tendon sheath. This usually occurs as a result of a direct injury or irritation in which the tendon rubs over a bony prominence; this is referred to as a tenosynovitis.

    Tendinosis is degenerative changes in the tendon.

    Diagnosis is primarily clinical. Pain is reported in the region of the anterior shoulder located over the bicipital groove, occasionally radiating down to the elbow.

  • The pain is aggravated by activities that require shoulder flexion, forearm supination, and/or elbow flexion.

  • Pain is usually exacerbated by initiating activity.

  • Some describe fatigue with shoulder movements.

  • The symptoms are alleviated by rest, ice, massage, stretching, and, sometimes, heat.

  • Night pain is not uncommon.

    Physical Causes

  • Poor lifting techniques

  • Chronic repetitive upper extremity activities (shoulder/elbow flexion)

  • Impingement syndrome

  • Rotator cuff pathology

  • Biceps subluxation

  • Shoulder girdle muscle imbalances

  • Poor posture

  • Overload (usually eccentrically)

  • Lack of flexibility/capsular tightness

  • Direct trauma

  • Multidirectional shoulder instability

  • Calcifications of the tendon

  • Osteoarthritis and spurring

    The majority of the information provided above was brought to you by Linsay Sunderland.

    Author: Linsay Sunderland

    Date Posted: November 4th, 2008 

    Supplied by: Linsay Sunderland

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