Biceps Tendonosis vs Tenosynovitis: a question of palpatory skills

For patients presenting with anterior shoulder pain, specific diagnosis is of utmost importance in order to determine an effective, and efficient treatment approach.  A common source of pain in this region is pathology of the long head of the biceps tendon.  Functionally, the biceps tendon is subject to impingement in the sub-acromial space.  This is most often seen in those with typical ‘upper cross posture’ consisting of anterior head carriage, increased upper thoracic kyphosis, protraction of the scapulae, and internal rotation of the glenohumeral joints.

Two very important differentials for this structure are degenerative tendonosis, and the very similarly presenting tenosynovitis (inflammation of the surrounding synovial sheath).  This distinction in important considering the fact that the underlying pathologies are significantly different and treatment of such pathologies can cause the symptoms to progress if an incorrect modality is selected.  For example, if a treatment of biceps tendonosis is made treatment modalities selected may include aggressive myofascial/active release to remove degenerative fibrosis, as well as an eccentric training program targeted at regenerating the tendon proteins and destroying the angio-fibroblastic hyperplasia which has formed (note, please see the works of Khan for a complete description of the pathological findings in degenerative tendonosis).  Such treatments, if performed on a tenosynovitis, will cause an irritation of the inflammatory process surrounding the tendon and thus will cause the condition to worsen dramatically.  Conversely, if one incorrectly assumes a diagnosis of tenosynovitis, when tendonosis is the actual problem, attempts to treat the condition solely with anti-inflammatory measures will produce no significant effect on combating the histopathology of the condition.

Unfortunately, as is commonly the case, there are no orthopaedic tests that are proven to be useful in differentially diagnosing these common conditions.  Impingement tests such as Neers and Hawkins simply provide the generally idea that there is a painful structure beneath the acromion…the list of potential culprits is very large including the subacromial bursa, supraspinatus tendon, infraspinatus tendon, the A/C joint capsule, the G/H joint capsule, etc.  Further, the list of pathologies that can affect these structures is even longer and more diverse.  Tests stressing the biceps tendon will tell you little more than the fact that the biceps tendon ‘may’ be involved (the parenthesis around the word ‘may’ are included as the specificity of tests for this structure are poor at best).

As is most often the case, the practitioner is left only with his or her palpatory skills and knowledge of clinical anatomy to correctly make this diagnosis.  After the long head of the biceps is accurately located (if this is not within your ability, please visit www.FunctionalAnatomySeminars.com to sign up for an Upper Limb F.A.P. seminar soon), use of the painful arc sign may be helpful.  Once the painful section of the tendon is located under the palpating contact with the shoulder in a neutral position and the elbow bent to 90 degrees, passively extend the patients shoulder and elbow in order to slide the biceps tendon under your contact.  If the pain is no longer located under your palpating contact, than you can assume that with movement of the tendon, the painful section is no longer under your palpating contact.  This suggests that the pathology is most likely in the tendon itself and not in the synovial sheath.  This is because with movement, the sheath’s position does not change.  If the pain remains under your contact, than the structure involved is most likely the sheath.  If this finding is coupled with a palpation of crepitus (a feeling of “creaking” or “rubbing”) then this is further evidence that the sheath is involved as this is a finding commonly associated with an inflammatory condition.

Of course, any good manual therapist would couple this finding with a thorough and detailed history looking for hints pointing in the direction of the pathology.  For example, a complaint of night pain would be associated with an inflammatory tenosynovitis, while pain that decreases during exercise would hint a tendonopathy.  In addition, it goes without saying that in order to treat these complex conditions one must address the functional cause via specific rehabilitation measures in addition to applying the proper passive care modalities.