Biceps Tendon Injuries

The biceps is a muscle in the upper arm that helps flex the elbow, supinate (face palms of the hand upwards) the forearm, and to a small degree flex the shoulder. This discussion focuses on injuries to the biceps muscle/tendon unit in the shoulder joint. There is also a biceps tendon further down the arm at the elbow that can also be injured. This is discussed in further detail in the elbow section under “distal biceps ruptures.”

The most common injury to the biceps is tearing, fraying, and occasionally rupture from its connection point in the shoulder. This is caused by degenerative changes to the tendon itself, as well as mechanical injury to the tendon from bone spurs, heavy lifting, and different types of sporting activities. Another cause of biceps injury is in the setting of a subscapularis tear (a type of rotator cuff tear), where the biceps actually dislocates from its normal position in the shoulder.

The most common complaint is pain over the front of the shoulder; however, biceps tendon injuries can have symptoms consistent with rotator cuff tears or arthritis in the shoulder or collarbone. These include pain with activity/overhead motion, weakness, and night pain. Some patients with biceps injuries have pain only with certain movements that activate the biceps muscle. Motions such as flexing the elbow, carrying heavy weights, and even throwing movements are some common complaints. On rare occasion, patients will hear a “pop” in the shoulder that is followed by severe pain and the development of bruising down the front of the arm over the first day. What has occurred is a rupture of the biceps tendon, and the pain can be expected to last for a few days as the inflammation resolves.

The first line of treatment is non-operative management. This includes anti-inflammatory medications (such as Ibuprofen or Naproxen), a home exercise program or supervised physical therapy, and occasionally a corticosteroid injection around the injured tendon. If you continue to have pain after an appropriate course of non-operative treatment, surgery may be required to alleviate your pain.

Biceps tendon tears are treated in one of two ways: biceps tenotomy (cutting the tendon and letting it retract) vs biceps tenodesis (cutting the tendon and reattaching it to the arm bone). The goal of cutting the tendon is to remove the injured and diseased part of the tendon from the shoulder joint and biceps groove (where some research has suggested might be the area causing the most pain). No differences in pain relief and return to activities has been demonstrated through research. The downside of a tenotomy is the possibility of a “popeye” deformity where the biceps muscle can “ball up” in the arm as the cut tendon retracts down the arm. The popeye deformity does not happen 100% of the time, and for many people, the slight abnormal appearance of the muscle is not too big a deal. A second downside of a tenotomy is the small possibility of short-term cramping of the muscle in the early post-operative period. This usually doesn’t last long, and is very uncommon after 6-9 months after surgery. In contrast to a tenotomy, a biceps tenodesis can prevent the popeye deformity and most cases of cramping. However, this comes at the expense of a bigger, more invasive surgery that often requires an open incision near the arm pit (1-2 inch incision). Secondly, rehabilitation is prolonged after a tenodesis in comparison to a tenotomy. A sling is required for the first 5-6 weeks, and supervised physical therapy is initiated, similar to a rotator cuff repair. In contrast, patients who have undergone a biceps tenotomy can return to activities as soon as they feel comfortable. If you have spontaneously ruptured your biceps tendon, you have in-essence done your own biceps tenotomy, and no surgery is required.

A dislocating biceps tendon is often caused by a tear of the subscapularis muscle. Treatment of the biceps, in addition to repair of the torn subscapularis muscle, is the same – either a biceps tenotomy or tenodesis, depending on patient preference and the condition of the tendon.