Biceps Tendon Tear (Tendonitis)
By Joe F de Beer
What is Biceps Tendon Tear?
The Biceps is an upper arm muscle that acts across the shoulder and elbow joints. At the elbow, it helps to bend the joint. At the shoulder, its function is more complex and incompletely understood. The biceps has two tendons around the shoulder: the long tendon passes inside the joint via a groove in the ball and attaches to the upper end of the shoulder socket, and the short tendon passes outside the joint to an adjacent bony outgrowth (coracoid). The long tendon of the biceps is the problematic entity in shoulder pain.
What are the early signs of a Biceps Tendon Tear?
Pain around the front of the shoulder, arm and sometime passing down the upper limb is suggestive. The pain occurs with movements of the arm (mechanical in nature) Pressure on the groove is painful, and an injection of a local anaesthetic drug in the groove, under ultrasound control, provides relief. Partially torn tendon and SLAP tears can cause obstruction to movements of the arm and gives an unpleasant sensation of “clicking”. Complete tears of the biceps tendon can result in a “Popeye” like muscle appearance, deformity.
How long do I stay in hospital after Biceps Tendon surgery?
The Biceps Tendon surgery is done in the Day Clinic and requires no overnight hospitalisation.
Should I wear a brace after Biceps Tendon surgery?
A sling will be required for four weeks after surgery.
What exercises can I do after Biceps Tendon surgery?
After the six weeks the elbow can be gradually stretched into full elbow extension. Formal strength may return after 2-3 months and sport activity after six months. Dr Joe de Beer will advise on the rehabilitation. Intensity of the surgery as well as age will determine the rehabilitation path to follow.
Anatomy of Biceps Tendon Tear
The Biceps is an upper arm muscle that acts across the shoulder and elbow joints. At the elbow, it helps to bend the joint. At the shoulder, its function is more complex and incompletely understood.
The biceps has two tendons around the shoulder: the long tendon passes inside the joint via a groove in the ball and attaches to the upper end of the shoulder socket, and the short tendon passes outside the joint to an adjacent bony outgrowth (coracoid).
The long tendon of the biceps is the problematic entity in shoulder pain.
Arthroscopic view (Left) and diagrammatic representation (Right) of the Biceps tendon passing through the groove.
Diseases / disorders of the tendon:
1. Inflammation of the tendon: Bicipital tendonitis. The Long tendon of the biceps slides in a groove on the shoulder ball during movements of the arm. Friction between the surfaces result in “soreness” of the tendon, called “Tendonitis”. Within the shoulder, the tendon appears “Red” with tiny blood vessels on its surface. Untreated, the tendonitis progresses to fraying and tears.
Bicipital tendonitis
2. Fraying / partial tearing of the tendon. Persistence of friction on an inflamed tendon leads to this condition. The tendon appears frayed, which implies separation of individual fibres.
Frayed / torn biceps tendon.
3. Subluxation of the biceps tendon out of its groove – when the biceps tendon subluxes out of its groove, it happens due to the ligament (transverse ligament) holding it in its groove degenerating. The biceps tendon then rides on the insertion of the subscapularis tendon, and may well start “cutting it off”. In such cases the biceps tendon needs to be placed back in its groove, and the tear in the subscapularis repaired.
Subluxation of the biceps tendon
4. Complete tears / rupture of the tendon. Persistence of friction on a frayed out tendon leads to this condition. The tendon cannot be seen from within the joint as it slips into the groove on the ball. The resultant slack on the muscle leads to a “Popeye” like muscle deformity.
Torn biceps tendon
5. Tears around the tendon attachment at the upper end of the shoulder socket (SLAP tears). These are seen in throwing athletes.
Diagnosis of Biceps Tendon Tear
Clinical
Biceps tendon disorders can present in different ways.
- Pain: Pain around the front of the shoulder, arm and sometime passing down the upper limb is suggestive. The pain occurs with movements of the arm (mechanical in nature) Pressure on the groove is painful, and an injection of a local anaesthetic drug in the groove, under ultrasound control, provides relief.
- Clicking: Partially torn tendon and SLAP tears can cause obstruction to movements of the arm and gives an unpleasant sensation of “clicking”.
- Deformity: Complete tears of the biceps tendon can result in a “Popeye” like muscle appearance.
Complete tears of the biceps tendon can result in a “Popeye” like muscle appearance
Radiology of Biceps Tendon Tear
Xrays do not reveal biceps problems.
MRI and ultrasound are sometimes useful. Fluid around the tendon, and displacement out of the groove are some of the indicators of possible biceps pathology.
Arrows show an empty groove on ultrasound (Left) and MRI (Right)
Arthroscopy of Biceps Tendon Tear
Arthroscopy accurately shows the inflamed, frayed or torn biceps tendon and SLAP tears.
Inflamed, frayed or torn biceps tendon
Treatment of Biceps Tendon Tear
Conservative
- Avoidance of movements that cause shoulder pain.
- Cortisone injections into the groove, under ultrasound control, to reduce inflammation.
Cortisone injection under ultrasound to reduce inflammation
Surgery of Biceps Tendon Tear
Arthroscopy identifies the problem and should be used to simultaneously treat the problem. The biceps tendon is detached from its attachment on the upper socket and is transferred to a hole created in the groove on the ball using biodegradable screws or anchors (Biceps tenodesis). This eliminates the sliding of the tendon and thereby removes friction. Pain relief is immediate and complete.
Pain relief of the biceps tendon is immediate
Transfer of the tendon to the groove using metal / biological screws and devices
Subpectoral biceps tenodesis: the tendon of the biceps is fixed to its groove by making an incision in the axilla. This is a very solid fixation, and the small incision is hardly noticeable afterwards, as it is in the fold of the axilla.
Another method that can be used in elderly individuals is simply detaching the tendon from the socket and allowing it to slip down the groove (Biceps tenotomy). Although similar to a rupture, this method has been shown to provide excellent relief of pain and is ideal in patients fro whom a cosmetic deformity is not an issue.
SLAP tears are repaired arthroscopically to the detached area of bone using tiny anchors. Severe tears are excised and the tendon may be transferred to the groove as described above.
Recovering from Biceps Tendon Tear
Post-operative care
The arm should be rested till the repair is firmly in place. Usually, three weeks of rest is sufficient. Thereafter, gradual passive and active exercises are begun and continued till full function is achieved.
Further reading
National Institutes of Health (NIH) (.gov)
Diagnosis and treatment of biceps tendinitis and tendinosis