M75.20 Bicipital tendinitis, unspecified shoulder

Name of the Condition

• Bicipital tendinitis, unspecified shoulder
• Also known as biceps tendonitis

Summary

Bicipital tendinitis is inflammation of the long head of the biceps tendon at its attachment to the shoulder. This condition causes shoulder pain and may limit arm mobility. It typically affects the dominant shoulder but can occur in either shoulder.

Causes

Repetitive overhead activities or shoulder use. Acute shoulder injury or trauma. Degenerative changes from aging. Overuse from sports or occupational tasks.

Risk Factors

• Engaging in sports with repetitive shoulder motions (e.g., tennis, swimming)
• Advanced age leading to tendon wear
• Poor shoulder mechanics or posture
• Previous shoulder injuries

Symptoms

• Pain or tenderness in the front of the shoulder
• Pain worsening with overhead movements or lifting
• Weakness or fatigue in the shoulder
• Clicking or snapping during shoulder motion

Diagnosis

Physical examination for shoulder pain or tenderness. Medical imaging (MRI or ultrasound) to assess inflammation. Orthopedic evaluation of movement and pain patterns.

Treatment Options

• Rest and activity modification to reduce strain
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief
• Physical therapy to strengthen and stretch the shoulder
• Corticosteroid injections for severe inflammation
• Surgery (rare, for persistent cases)

Prognosis and Follow-Up

Most cases improve with conservative treatment within weeks to months. Follow-up may include monitoring pain levels and functional improvement. Physical therapy is often recommended to restore strength and prevent recurrence.

Complications

• Chronic pain or persistent weakness
• Tendon rupture (rare)
• Reduced shoulder mobility
• Recurrence with repetitive strain

Lifestyle & Prevention

• Avoid repetitive overhead motions when possible
• Maintain proper shoulder mechanics during activities
• Strengthen shoulder muscles through targeted exercises
• Use ergonomic adjustments in work or sports

When to Seek Professional Help

Seek care if pain persists beyond a few weeks, worsens, or limits daily activities. Immediate attention is needed for sudden severe pain, inability to move the shoulder, or signs of tendon rupture.

Tips for Medical Coders

Document the affected shoulder (right/left/unspecified) and any contributing factors. Include details on onset, duration, and treatment response. Ensure clinical correlation with imaging or physical exam findings to support the diagnosis.