Biceps tendon problems.

Site

Long head of biceps in the bicipital groove

Pain pattern

Front-of-shoulder, on lifting and pulling

Imaging

• Ultrasound first-line
• MRI selective

First-line

Physiotherapy + selective injection

Surgical

Biceps tenodesis (most common)

Anatomy.

The biceps muscle has two heads. The long head originates inside the shoulder joint, attaching to the superior labrum of the glenoid; from there it runs through the bicipital groove on the front of the humerus and joins the short head distally to form the biceps muscle. The long head is uniquely vulnerable because of where it sits — passing through a high-load, high-movement region of the shoulder.

What can go wrong.

Biceps tendon problems fall into a small number of recognisable patterns:

• Long head biceps tendinopathy — chronic degenerative change of the tendon, with pain on the front of the shoulder, particularly on lifting.
• Bicipital tendinitis — acute or subacute inflammation, often co-existing with rotator cuff disease.
• SLAP-related disease — injury at the biceps anchor on the superior labrum. See the SLAP tear page.
• Long head biceps rupture — the tendon ruptures (usually at the biceps anchor or in the bicipital groove), producing a classic "Popeye" deformity of the upper arm muscle bulk.

Symptoms.

• Pain at the front of the shoulder — localised, point-tender over the bicipital groove.
• Pain on lifting, pulling, or carrying weight in front of the body.
• Occasionally an audible click or pop with movement (often subluxation of the tendon out of its groove).
• Sudden severe pain with a visible deformity (in rupture).

How Dr Coory diagnoses it.

Examination identifies point tenderness over the bicipital groove, positive Speed's and Yergason's tests, and pain reproduced on resisted flexion of the elbow. A diagnostic local anaesthetic injection into the bicipital groove is the most useful test — if the pain disappears, the symptom source is confirmed. Ultrasound is the first-line imaging investigation; MRI is reserved for assessing the biceps anchor and any associated SLAP pathology.

Non-operative treatment.

• Activity modification — reducing the provoking lifting and pulling activities.
• Targeted physiotherapy.
• Image-guided corticosteroid injection into the bicipital groove (or, where SLAP is involved, into the joint).

Surgical treatment: biceps tenodesis.

For persistent symptoms despite non-operative treatment, the contemporary procedure is biceps tenodesis — detaching the long head from its problematic intra-articular anchor and re-attaching it to the upper humerus. The procedure removes the painful tendon segment from the joint while preserving the cosmetic contour and the strength of the biceps. Recovery is faster and more predictable than SLAP repair in older patients.

Biceps rupture.

A sudden, audible "pop" with a Popeye deformity in an adult is most often a long-head biceps rupture. In most patients (particularly older adults), the rupture is left untreated — the loss of flexion and supination strength is small (typically 10–20%) and the cosmetic deformity does not change function. Surgical repair is reserved for younger active patients where the cosmetic and strength outcome is more important.

Frequently asked questions.

References.

1. Mariani EM, et al. Rupture of the tendon of the long head of the biceps brachii. Clin Orthop Relat Res. 1988;228:233–239.
2. Boileau P, et al. Arthroscopic biceps tenodesis or SLAP repair in patients over 50. J Shoulder Elbow Surg. 2009;18(2):247–253.
3. Provencher MT, et al. Long head of biceps tendon disease. Arthroscopy. 2011;27(4):581–592.