Injuries and conditions

Biceps Tendon Tear

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.

What is a Biceps Tendon Tear?

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:

Partial (does not completely sever the tendon) or
Complete (will split the tendon into two pieces).

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:

Your symptoms cannot be relieved by nonsurgical treatments
You develop cramping in the muscle or pain
You require complete recovery of strength

Medical diagram showing the anatomy of the shoulder showing where Biceps Tendon Tears most commonly occur.

What causes Biceps tendon tears?

There are two main causes of biceps tendon tears:

Injury

Occurs typically after falling hard on an outstretched arm or lifting something too heavy
Generally, this involves abnormal force through a normal tendon

Overuse

Many biceps tendon tears are due to gradual fraying that occurs slowly over time
This does occur naturally as we age; however, it may be worsened by overuse – repeating the same shoulder motion over time. This may be with normal daily activities, certain types of sport or work environments.
Generally, this involves normal force through an abnormal tendon
Overuse can also lead to other shoulder problems, including biceps tendonitis, shoulder impingement, shoulder spur, and rotator cuff injuries and tears. With additional conditions around the shoulder, more stress is placed on the biceps tendon, making it more likely to weaken or tear.

What are the risk factors for Biceps tendon tears?

The risk factors for biceps tendon tear increase in the following circumstances:

Age: older people have more wear and tear around their tendons than young people
Heavy overhead activities: too much load during weightlifting is a good example of this risk, however many jobs that require heavy overhead lifting create excess wear and tear on the tendons. Workplace injury is a common cause of tendon tears overall.
Shoulder overuse: repetitive overhead sports, such as swimming and tennis can lead to more tendon wear and tear
Smoking: nicotine is a recognised cause in affection the tendon health and overall quality
Corticosteroid medications: corticosteroid (either taken orally or injected into the shoulder) has been linked to increased risk of muscle or tendon weakness.

How are Biceps tendon tears diagnosed?

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.

Black and white image showing a biceps tendon tear with the popeye sign

With partial tears the presentation may include the following symptoms:

Sudden, sharp pain in the upper arm, sometimes an audible pop or snap over the front of the shoulder with certain movements
Cramping of the biceps muscle after strenuous use of the arm
Pain or tenderness over the front of the shoulder (anterior shoulder pain)
Difficulty with turning the hand palm up or down (supination and pronation)
If the biceps tendon moves out of the groove (dislocation) then this may severely limit shoulder function and affect the rotator cuff muscles (subscapularis in particular)

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.

What are the treatment options after a Biceps tendon tear?

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:

Partial tear with pain that does not resolve
Shoulder pain and arm cramping
Requirement for complete recovery of strength
High-level athletes
Manual workers and those that require repetitive overhead arm positioning

When should you consider surgery for a biceps tendon tear?

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.

Options at surgery

Biceps tendon repair (SLAP repair)

This is more for younger patients where the tendon itself is found to be in good condition at surgery but torn off the top of the glenoid (socket)

Biceps tenodesis

The damaged/torn section of the tendon is removed and the remaining healthy biceps tendon is reattached to the upper arm bone (humerus) with an incision under the armpit.
This is a very successful operation and removing the torn biceps tendon usually resolves symptoms and restores normal function

Biceps tenotomy

In some cases it may be best to release the inflamed and torn biceps tendon from the shoulder joint without reattaching it, this is called a “biceps tenotomy”. This is ideal in the older patient and does not weaken shoulder or arm function; however, in some cases it may leave a “Popeye” bulge over the arm. Patients who have a tenotomy for the right reasons do very well and return to normal shoulder function.

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.

Time Urgent Conditions

Biceps tendon tear with a dislocation (out of the groove)

When the biceps tendon is “subluxed” or “dislocated” out of the groove it can cut into the subscapularis tendon and cause further damage
You should consider surgery sooner rather than later

Other considerations

Function

If you are unable to undertake basic tasks or to look after yourself, unable to drive, unable to get dressed, or have difficulty with hygiene and toileting.

Pain

Pain with activity and even at rest
Night pain, especially if it wakes you from sleep
Unable to sleep on your affected shoulder
Increasing requirements of pain relief tablets
Multiple failed cortisone injections
Not responding to physiotherapy

Work

If it is limiting your ability to work
Especially if you are in a manual job requiring repeated overhead activity

Sport

If you are unable (even after a period of rest and activity modification) to participate in your chosen leisure activity or sport and you wish to continue to do so

Prevent further damage

There are certain conditions where it may be better to repair your shoulder before further damage occurs
Dr Pant will carefully analyse your MRI scan and determine if this is the case for you (especially in younger patients)

What if the Biceps tendon has already ruptured? Can you reattach a ruptured/torn biceps tendon?

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.

About Dr Pant

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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Biceps Tendon Tear