Biceps Tendon Pathology

The biceps muscle has two tendons in the shoulder; the long head and the short head (Figure 1). Pain at the front of the shoulder commonly occurs from conditions affecting the long head of the biceps tendon.

This biceps tendon arises from the superior labrum at the top of the glenoid (Figure 2). It passes underneath the transverse humeral ligament in the groove between the lesser and greater tuberosity of the humerus. The biceps tendon ends by inserting into the proximal radius at the elbow region. The biceps works as a humeral head depressor, strong flexor of the elbow, and supinator of the forearm.

Conditions Affecting the Biceps

Biceps tendonitis is an inflammation or irritation of the upper biceps tendon (Figure 3). Recurrent microtrauma to the tendon, overuse and repetitive overhead activities, leads to biceps tendonitis. These activities include sports such as baseball, tennis, swimming, or lifting weights. It usually occurs in association with other shoulder problems. Conditions that are associated with biceps tendonitis are shoulder impingement, tears of the glenoid labrum, shoulder instability, shoulder joint arthritis, and rotator cuff tears. Shoulder impingement is a main cause of biceps tendonitis. The soft tissues between the humeral head and the acromion can be pinched or squeezed with arm movements.

The symptoms associated with biceps tendonitis are anterior shoulder pain and bicipital groove tenderness (Figure 4). The speed test is used to clinically evaluate biceps tendonitis. The arm is supinated and the elbow is extended (Figure 5). The patient is asked to actively forward flex the shoulder while the examiner is applying resistance to the movement. Tenderness over the bicipital groove indicates tendonitis of the long head of the biceps.

Conservative treatment for biceps tendonitis includes rest, ice, physical therapy and steroid injections around the tendon (not through the tendon).

If the condition does not improve with conservative treatment, surgical intervention will be considered. A biceps tenotomy is performed when the damaged biceps tendon is released from its attachment. The surgeon will cut the biceps tendon and let it fly. It is done in the elderly and in low demand patients. The injury may result in “a Popeye bulge” and the patient may have subjective cramping.

A biceps tenodesis will be performed to remove the damaged section of the biceps and the remaining tendon is reattached to the upper arm bone (humerus). This is usually done for active high demand patients.

In a biceps tendon rupture (proximal or distal), the biceps tendon may rupture at the top of the bicipital groove around the shoulder or it may rupture at the radial tuberosity at the elbow. A proximal rupture will occur at the bicipital groove. The muscle moves towards the elbow (Popeye muscle) (Figure 6). There is minimal loss of function with a long head rupture because the short head of the biceps remains attached to the coracoid process.

A distal biceps tendon rupture occurs at the radial tuberosity of the elbow (Figure 7). A “pop” is felt at the elbow when the tendon ruptures. The rupture must be repaired, otherwise there will be a loss of flexion and supination.

The hook test is used to clinically evaluate a distal biceps tendon rupture. The patient actively supinates and flexes the elbow to 90° and if the distal biceps tendon can be hooked from the lateral side of the elbow, then the biceps tendon is intact (Figure 8).

A proximal biceps tendon rupture may be treated either conservatively or surgically. Nonoperative treatment is utilized for elderly patients. Conservative treatment will include rest, ice, and physical therapy. Most patients will become asymptomatic after 4-6 weeks. Surgical treatment will include reattaching the torn section of the tendon to the bone (tenodesis). It is usually done in association with other reconstructive cuff surgery. It is rarely done for cosmesis.

Treatment for the distal biceps tendon rupture will include surgical treatment. Avulsion of the distal biceps tendon is treated with tenodesis using sutures to anchor the tendon into the radius.

In a biceps tendon subluxation or dislocation, the transverse humeral ligament and pulley system, which holds the biceps tendon within the bicipital groove can become injured. When it is injured, the biceps tendon subluxes or dislocates in and out of the bicipital groove. This is most often due to incompetency of the pulley system or may be associated with a partial or complete tear of the subscapularis tendon (Figure 9). Movement of the biceps tendon within the groove may be accompanied by a snapping sound.

Conservative treatment for a biceps tendon subluxation includes rest, ice, physical therapy, and steroid injections located around the tendon (not through the tendon). Initially the treatment is usually conservative, if the condition does not improve with conservative treatment a tenodesis will be performed.

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