Shoulder Arthroscopy

Biceps Tendonitis, Partial Biceps Tear, Biceps Subluxation and

Biceps Rupture
By Alan M. Reznik, MD, MBA

The biceps muscle starts at the elbow, passes up the arm and splits into two tendons or "heads". The shorter tendon ends at the coracoid process of the "shoulder blade" (the scapula) and the longer one enters the shoulder joint. There, the longer end (the “long head”) attaches to the top of the socket (the glenoid) at a cartilaginous lip that covers the edge of the socket (the labrum). The long head of the biceps can be injured by repetitive motion, local trauma, rapid extension of the arm, force applied while trying to actively flex the elbow or during a fracture or dislocation of the shoulder. It can be associated with rotator cuff tears and can subluxate with subscapularis tears. Its true function in the shoulder joint is heavily debated in the orthopedic and sports medicine community. At the elbow it acts, partnered with the short head of the biceps, in flexion of the elbow and with supination of the hand (clockwise rotation of the right hand and counter-clockwise on the left).

Biceps tendonitis is the most common problem seen in the long head of the biceps. It can often be treated with anti-inflammatories, ice and rest. In chronic cases, injection or therapy may be needed. Occasionally there is a structural issue, and tenolysis (release of the tendon sheath), an arthroscopic decompression of the shoulder or a tendonotomy (release of the tendon itself) may be required.

A biceps tendon injury typically involves a partial or complete tear of the longer tendon. It is more common after the age of forty. Many times it is associated with an acute injury or a painful pop. Then, the muscle attached to the long head tends to “ball up” further down the arm. The “short head” almost always remains intact. Prior to the injury, some patients often have a long history of inflammation of the tendon (chronic biceps tendonitis). When that occurs, it is usually due to years of wear and tear on the shoulder. It is often associated with repetitive overhead lifting, chronic inflammatory tendonitis and a heavy lifting injury, or repetitive work trauma. In other cases, a more severe sudden traumatic injury is the cause. This is more common in younger patients but can occur at any age. A traumatic torn biceps sometimes occurs during heavy weightlifting or from actions that cause a sudden load on the upper arm, such as a hard fall with the arm outstretched during competitive sports. Forced extension of the elbow against resistance or a fall in a position that forces the tendon to trap between the humeral head (ball of the shoulder) and the ‘sharper' bone edges of the scapula or acromion can also cause a tear or rupture.

Please note: Tears of the biceps tendon at the elbow are a completely different problem. Both heads of the biceps muscle join and attach in one common location on the proximal radius. Together, they are a major flexor of the elbow and these tears should, in general, always be repaired. This discussion is focused on injuries to the long head of the biceps.

Treatment

Many partial and even complete tears can be treated without surgery. A well preformed physical exam by an orthopedic surgeon and an X-ray of the shoulder are often the best ways to see what treatment is most appropriate. About 50% of long head of the biceps tendon ruptures are associated with rotator cuff tears (mostly supraspinatus tears). Subluxation of the long head is associated with a subscapularis tear. If there are signs and symptoms associated with a rotator cuff tear found on examination, further testing may be needed. When a patient has significant symptoms, an MRI is frequently required to make the diagnosis of other shoulder problems associated with a biceps rupture.

Surgery is often reserved for patients with evidence of other concomitant shoulder problems. When the long head of the biceps is completely torn, the acute soreness will resolve in weeks. Some patients actually feel better than before the injury. If the muscle itself is painful with activity, the shoulder needs to be examined. If patients have weakness and pain with supination of the hand (clockwise rotation of the right hand and counter clockwise on the left), after failing conservative measures, a biceps tenodesis may be required. Biceps ruptures are also frequently associated with bone spurs near the tendons path into the shoulder joint. When these are painful they should be removed. If am MRI confirms the rotator cuff is torn, it should be repaired at the same time.

Special considerations: When the biceps is subluxed (out of its normal groove) and the subscapularis is torn, releasing the tendon may be necessary to protect the subscapularis repair. When there is a tear of the superior labrum (a cartilage “lip” on the socket of the shoulder joint) and it involves the attachment of the biceps, repair of the labrum (lip) is needed, and a release of the tendon may also help resolve the symptoms (this is a newer concept and there is no clear agreement on the best treatment at this time, your surgeon will have to make a judgment based on the findings at the time of surgery).

When needed, a Biceps tenodesis is a surgical procedure that anchors the ruptured end of the biceps tendon to the upper end of the humerus. Dr. Reznik performs arthroscopic evaluation of the shoulder to check for other related injuries to the shoulder first. Once any rotator cuff issues are treated, if a tenodesis is needed, it is done through small incisions over the front of the humerus. Depending on the length and condition of the tendon, the location of the tenodesis will vary. Newer arthroscopic tendon transfers are also possible in some cases. The type of procedure will depend on your anatomy and the problem found at the time of surgery. When tenodesis is performed, the tendon itself can be fixed in place with a special absorbable screw, sutures or both. The surgery is done on an outpatient basis with the goal of decreasing pain with activity and improving overall function in the affected arm.

Fig 1: An Intra-articular view (inside the ball and socket of the shoulder) of a normal biceps tendon.	Fig 2: An inside view of a torn biceps tendon. See the torn end facing the camera head on.
Fig 3: The tendon delivered out of a small incision.	Fig 4: Sutures placed for the repair.
Fig 5: Tendon reattached to the bone in a new location. Revised 5-23-09 AMR

Biceps Tenotomy: In some cases, the biceps is partially torn and painful. The tendon is swollen, worn, frayed or inflamed in its groove. Forward flexion of the arm, supination of the hand and pressing on (palpating) the bicipital groove are all painful. If the non-dominant arm is involved, the patient has a low demand occupation and the shape of the muscle (cosmetic appearance) is not a concern, a tenotomy (a release of the tendon) can be an excellent option with good pain relief and a shorter recovery time than a tenodesis.

Page 2: Post Operative instructions after a Biceps Tenodesis

8/4/09