Biceps Tendon Disorders at the Shoulder
The Biceps Tendon has two “heads”, or origins, that contribute to it: the Long Head and the Short Head. The Long Head goes through the shoulder, where it frequently degenerates from overuse and becomes painful. Depending on the severity of its degeneration, the Long Head of the Biceps can be intact but degenerative and painful, partially torn or fully torn. The Long Head of the Biceps Tendon can also subluxate or dislocate out of its groove. All of these conditions can lead to pain in the front of the shoulder.
Complete tears of the Long Head of the Biceps occur only in tendons with preexisting degeneration, regardless of whether or not there was any preexisting pain. Long Head Biceps Tendon tears often occur with a pop, which is often associated with pain, swelling and bruising over the front of the shoulder. The Biceps muscle retracts down the arm, causing it to look larger and more balled up. This is known as the “Popeye sign”. A Biceps Tendon Tear at the shoulder is different than a Distal Biceps Tendon Tear at the elbow. When the Distal Biceps Tendon tears at the elbow, then both biceps muscle heads are detached, leading to significant weakness if it is not repaired. Almost all active patients want to have a Distal Biceps Tendon Tear at the elbow repaired. However, tears of the Long Biceps Tendon at the shoulder still leaves the Short Biceps Tendon intact. “Classic” Orthopedic teaching is not to repair these, as good function can result. For example, John Elway won his two Super bowls following a complete Long Biceps Tendon Tear in his throwing shoulder that was not repaired.
However, more recent research has questioned this classic teaching. Recent studies have noted that not fixing a Long Head Biceps Tendon Tear leads to a loss of 8-29% of elbow flexion strength and 21-23% of supination strength. Supination means rotating the forearm so that the palm of the hand is up, such as when using a screwdriver, turning a door handle, lifting heavy objects, etc. The recent literature has found that young and active patients with untreated Long Head Biceps Tendon tears frequently develop Biceps pain and dysfunction during heavy use. Therefore, it is now prudent to consider surgical treatment in young active patients following Long Biceps Tendon Tears. If the Long Biceps Tendon has completely torn, it can no longer be treated arthroscopically. Surgery for a torn Biceps Tendon is an Open Biceps Tenodesis, which is a repair of the Long Biceps Tendon about the upper part of the humerus bone. Open Biceps Tenodesis is optimally performed within 3-4 weeks, before the Biceps muscle contracts and scars in. Older, less active patients do not require surgery following a Long head Biceps Tendon Tear.
The vast majority, 95% or more, of Long Biceps Tendon problems are due to an underlying Rotator Cuff problem. Therefore, most Biceps problems are initially treated similar to how Rotator Cuff Tendinosis/degeneration is treated, with a Rotator Cuff and shoulder blade muscle strengthening program and a steroid injection. If non-operative treatment doesn’t work then, as long as the Biceps Tendon has not completely torn, the degenerative, partially torn or subluxed Long Biceps Tendon can be treated arthroscopically. An Arthroscopic Biceps Tenodesis can be performed at the same time that the underlying Rotator Cuff problem is addressed. An Arthroscopic Biceps Tenodesis anchors the Long Biceps Tendon near the top of the humerus bone, just outside of the shoulder.
After an Arthroscopic Biceps Tenodesis, the Biceps still bends the elbow, but the diseased portion of the Long Biceps Tendon is removed from the shoulder, relieving the pain. This works very well and adds no pain, problems or restrictions to a Rotator Cuff Repair.
Shoulder pain due to Long Biceps Tendon problems are fairly common, especially in association with Rotator Cuff problems. If an Arthroscopic Biceps Tenodesis is performed at the same time as any Rotator Cuff surgery, you probably wouldn’t even notice that it was done, except that the pain in front of the shoulder is gone.