A biceps tendon tear is a condition in which the long head of the biceps partially tears or ruptures from its attachment to the top of the socket. It commonly occurs in association with other painful shoulder conditions such as rotator cuff disease or osteoarthritis. In almost every case, this condition is managed without surgery, with no long-term effects to shoulder function.
The biceps muscle has two tendons at the shoulder–the short head and long head. The short head of the biceps is attached to the shoulder blade away from the joint and is rarely a cause of shoulder pain. The long head of the biceps travels in a groove on the front of the humerus bone, underneath the rotator cuff tendon, and into the shoulder joint to attach to the top of the socket and the superior labrum. Even if the long head of biceps ruptures, the short head remains attached to the shoulder blade.
Many different factors contribute to a biceps tear or rupture, including hand dominance, occupation such as construction or other manual labor, and recreational activities. Since the tendon takes a long, circuitous path to its attachment, between the tuberosities of the proximal humerus, it is particularly vulnerable to injury. Friction against surrounding bony structures with motion, or traction during overhead activities may contribute to this condition. Because a rupture of the biceps tendon is often the end result of chronic degeneration, it will typically occur in older patients. Moreover, it is often associated with other shoulder conditions, including rotator cuff tears and osteoarthritis.
SIGNS AND SYMPTOMS
Patients typically describe pain along the front of their shoulder at the location of the bicipital groove. This pain can occur with rest and with activity, and often worsens with activities above shoulder level. The patient may have tenderness in this area as well. If the patient also has instability of the biceps, snapping may occur as the biceps slip out of its groove with certain movements.
Patients who sustain a biceps rupture will typically describe a pop or snap associated with strenuous activity. They will complain of significant pain and may notice bruising of the arm following the injury. Some patients may also describe cramping of the biceps following the injury. Patients will develop a cosmetic deformity of the biceps, also called a “popeye sign”, as the muscle belly of the biceps drop down compared to the other side. Any weakness that is observed is typically a result of pain, since the short head of biceps, and the more powerful brachialis muscle, remain attached and preserve the patient’s elbow flexion strength.
This diagnosis of this condition is based on the patient history and examination. Specialized tests in certain shoulder positions may reproduce anterior shoulder pain during the examination. X-rays can identify conditions that may accompany biceps tears, such as osteoarthritis. While an MRI is not necessary to diagnose a biceps tendon tear or rupture, it can be helpful to confirm the diagnosis and to identify associated conditions, including rotator cuff tears. While an ultrasound is less commonly used, it serves as a helpful, quick imaging modality that can easily recognize biceps tendon ruptures and rotator cuff tears in patients who cannot obtain an MRI.
Many patients with a biceps tendon tear will respond to nonsurgical management. This approach often consists of a period of rest from strenuous activities and athletics. Periodic icing can be helpful to alleviate pain. Non-steroidal and anti-inflammatory medications can be prescribed to diminish inflammation and to improve pain. A home exercise program is often recommended which consists of simple rotator cuff and biceps stretching as well as strengthening exercises. For patients who do not respond to this initial approach, physical therapy can be prescribed in order to decrease inflammation and pain, improve range of motion and strength of the rotator cuff and biceps, and address any associated conditions. Finally, injections can be helpful for patients with significant pain. These injections are often performed under ultrasound guidance to improve accuracy into the biceps tendon sheath.
For the patients who continue to experience pain despite conservative management, or for those who have instability or tearing of the biceps tendon, surgery can be an option. Surgery is most often recommended to treat associated conditions such as rotator cuff tears. At the same time, the biceps tendon can either be treated by releasing the tendon from its attachment in the shoulder (tenotomy), or releasing and reattaching the tendon lower down on the humerus (tenodesis). The tenodesis requires a separate, very small incision on the upper arm.
Various factors determine the appropriate procedure for each patient, including age, hand dominance, activity level, and occupation. Postoperative recovery, including duration in a sling, the physical therapy protocol, and recovery time are most often determined by the primary surgery being performed at the same time as the biceps procedure.