The biceps tendon sits in a narrow groove in the front of the shoulder – with new trauma (acute) or wear and tear over time (chronic) the tendon may become inflamed and start to tear (like rope becoming frayed). The tear may be partial thickness or full thickness (complete rupture). Often patients present with biceps tendonitis (hyperink) and in some cases if the tendon has already ruptured – a popeye deformity over the arm.
Biceps tendon tears often occur with other conditions in the shoulder and therefore it requires careful workup and investigation to exclude SLAP tears, supraspinatus and subscapularis tendon tears, subacromial bursitis, shoulder spurs.
The Biceps tendon is at the front of your shoulder and is also referred to as the “long head of the biceps tendon” (LHBT); this tendon is a strong cord-like structure that connects the biceps muscle to the top of the shoulder socket.
A common presentation of a biceps tendon tear is pain at the front of the shoulder and weakness with certain shoulder movements. This is because the biceps tendon runs in a very narrow groove at the front and with inflammation/tears may weaken, become compressed, and or irritated. The biceps tendon normally glides about 2 cm during overhead shoulder movement.
Biceps tendon tears can be:
A complete tear will result in tendon rupture and loss of contour about the front of the arm, this is referred to as a “Popeye” sign.
Even though the “long” head of the biceps tendon is ruptured, the “short” head is still attached near the shoulder so most patients can still use their biceps even with a full rupture of the “long” head.
In fact, many patients can still function at a high level with a biceps tendon tear around the shoulder and only need simple treatments to relieve symptoms. You may benefit from surgery to repair the torn tendon if:
Injury
Overuse
The risk factors for biceps tendon tear increase in the following circumstances:
With a complete rupture of the biceps tendon – patients may present after a “pop” or with a “lump” over the middle of the arm (Popeye sign). There may also be bruising from the middle of the arm towards the elbow. In these cases, the diagnosis is clear on clinical examination.
With partial tears the presentation may include the following symptoms:
Examination
One of the most reliable orthopaedic shoulder tests is in isolating and assessing the biceps tendon. Direct palpation over the biceps tendon and certain provocative maneuvers can isolate the tendon and check for partial or complete tears. During this examination, it is crucial to identify other areas of potential damage that may coexist with biceps tendon tears.
Imaging
The first step is to obtain a plain X-ray even though this will not show the biceps tendon, it does provide an overall picture of the shoulder and can rule other conditions. Ultrasound can be useful to provide a general guide to the integrity of the biceps tendon and any inflammation-related fluid around its sheath. However, the best test is an MRI which will show the biceps tendon in great detail and any other areas of concern around the shoulder.
In most cases, pain from a long head of biceps tendon tear resolves over time. Some arm weakness or minor cosmetic deformity does not typically bother most patients.
Furthermore, if you have not damaged more important structures, such as the rotator cuff, then non-surgical treatment is a good option for you. This may include a period of rest, activity modification, non-steroidal anti-inflammatory medications, cortisone injection and physiotherapy.
If after a period of non-surgical treatment your symptoms do not resolve or if you have rotator cuff tears then you may need to consider surgical treatment options.
Indications for surgical treatment include:
If your condition does not improve with nonsurgical treatment, then surgery may be an option for you. Surgery may also be a better option if you have other associated shoulder problems, particularly those that are time urgent.
Surgery for biceps tendon tear is performed arthroscopically (keyhole); this allows your surgeon to assess the condition of the biceps tendon and other structures in the shoulder.
Biceps tendon repair (SLAP repair)
Biceps tenodesis
Biceps tenotomy
The key point is to remember which conditions in your shoulder are “time urgent” and which are not. Dr Pant will clearly outline this for you during your consultation.
Biceps tendon tear with a dislocation (out of the groove)
Function
Pain
Work
Sport
Prevent further damage
If the biceps tendon has already ruptured then it may still be possible to find it and reattach it with surgery. The younger the patient and more high demand their function is, the more likely that this is a good idea. In older patients (>65) it is best to leave a ruptured biceps tendon alone and the symptoms will gradually resolve. If a biceps tendon has already ruptured and you have ongoing shoulder pain and/or weakness it is important to exclude other conditions such as a rotator cuff tear (particularly the subscapularis tendon tear). This usually required a careful history, examination, and MRI scan.
Dr Sushil Pant is a leading Australian trained orthopaedic shoulder surgeon. He is the founder and medical director of the Sydney Shoulder Unit; and is a Shoulder Surgeon at Sydney Sports Medicine Centre at Sydney Olympic Park.
Enquiries between 8am-6pm (Mon-Fri) will be responded to within 30-60 minutes.
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Dr Sushil Pant is a leading Australian trained Orthopaedic Shoulder Surgeon. He is the founder and medical director of the Sydney Shoulder Unit; and is a Shoulder Surgeon at Sydney Sports Medicine Centre at Sydney Olympic Park.
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