What is a biceps tendon tear at the shoulder?
In this common injury, biceps tendon disruption occurs when there is a complete tear of its tendinous attachment site in the shoulder. Normally, the biceps muscle attaches via a short head and a long head, the latter of which arises within the joint as a fairly small (about half the diameter of the little finger) tendon, which travels within a sheath from the shoulder joint down into the arm, where it becomes muscular. The most common site of injury is along the tendon’s path between its insertion on the top of the glenoid (shoulder socket), and its transition at the muscle-tendon junction.
The biceps tendon’s role in shoulder function remains the subject of debate despite considerable investigative effort. In some patients, the long head of the biceps is thought to contribute as a humeral head “depressor,” whereas in others it seems to have no significance. There is little data to prove that loss of the biceps long head results in detectable weakness or compromise of function (except when accompanying other problems such as rotator cuff tear).
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How does a biceps tendon tear occur?
- Long head biceps tendon tears typically occur with a sudden “pop” while exerting a strain during some resistance activity
- Examples include hitting an overhead in tennis, swinging a golf club or lifting a weight
- Repetitive activities without any increased strain may lead to progressive compromise of the long head fabric, which, like its adjacent cuff, is often degenerative and can lead to eventual abrupt failure
What increases the risk for a biceps tendon tear?
- Age, especially given the fact that degenerative changes are almost always associated with tendon rupture
- Overhead sports, such as golf, tennis and weight-lifting
- Contact/collision athletes are not typically at risk, because those engaged in such endeavors are typically younger
- Heavy laborers, especially in middle age
- Those with poor physical conditioning (strength and flexibility)
- Inadequate warm-up before practice or play
What are the symptoms of a biceps tendon tear?
- The usual presentation is that of acute pain and “pop” in the front of the shoulder.
- Accompanying “popeye” muscle deformity, in which the disruption of the normal biceps muscle attachment leads to its retraction distally (down the arm). The subsequent appearance is that of a bulge in the mid-arm and a hollowed-out loss of normal contour above it.
- Often, a history of pain preceding the acute rupture
- Interestingly, for those with prior symptoms, tearing of the biceps can often lead to prompt and complete resolution of the pain that preceded the tear.
- Pain may be worse with shoulder and elbow motion
- Bruising in the arm or elbow after 24 to 48 hours
- Transient limitation in normal shoulder and elbow motion (secondary to pain)
- There may be discernable initial weakness during certain activities in which the biceps is involved (such as when lifting something heavy)
How is biceps tendon tear diagnosed?
- Long head biceps ruptures are diagnosed by physical exam, with the distinct “popeye” sign
- Accompanying signs can include swelling, tenderness and bruising
- Occasionally, less well-conditioned arms may not show an overt defect, and diagnosis is made based on imaging studies, in which the tendon is no longer in continuity.
Are there any special tests?
- The “Ludington” sign is elicited by having the patient clasp their hands behind their neck and ask them to flex their biceps muscles. Asymmetry demonstrates a long head tendon tear.
- MRI is the diagnostic test of choice for demonstrating loss of normal continuity of the long head, as well as associated shoulder abnormalities, such as rotator cuff tears.
How is it treated?
Non-operative treatment is indicated for most patients, who are able to successfully resume all pre-injury activities. Because the defect is usually cosmetic rather than functional, most patients are able to return to their activities with a non-operative approach very quickly. Initial treatment consists of medication and ice to relieve the pain, gentle active stretching and strengthening exercises and modification of activities to avoid those that are provocative (reproduce the pain). This program can often be carried out independently, though some patients will benefit from physical therapy.
It is not possible to surgically fix the torn tendon (sew it together). However, surgery is occasionally recommended to reinsert the tendon into the humerus (arm bone) (known as “tenodesis” of the biceps tendon). Surgery is most often recommended for (and requested by) younger, active individuals, especially those who require strength of wrist rotation. Surgery may also be performed for those patients who are unsatisfied with the “Popeye muscle” appearance of the arm. Surgery is also indicated in those undergoing surgical treatment for associated pathology, such as tears of the rotator cuff.
Operative treatment involves arthroscopic debridement (surgical clean-up) of the remnant long head tendon fragment within the joint, retrieval of the torn tendon and tenodesis (reattachment) to either soft tissue or bone. Many surgical techniques for reattachment have been described, most with good overall results. Many of the outcome series have included patients treated for concomitant problems, specifically repairs of the rotator cuff. Such inclusion may complicate interpretation of the results of truly isolated biceps tendon long head tears. Tenodesis techniques historically have relied on an open incision and insertion of the remaining long head tendon into a hole made in the proximal (top part of) humerus. Although a small open incision remains an excellent surgical alternative, recent emphasis has been placed on arthroscopic techniques, which reattach the tendon to adjacent soft tissue or the proximal humerus (top of the arm bone).
Possible complications of non-operative treatment include:
- Failure to recognize associated pathology, which is very common, such as tears of the rotator cuff. Acute long head biceps tendon rupture should direct the clinician to evaluate and when necessary, image the adjacent rotator cuff tendon for integrity and function.
- Cosmetic deformity, which over time may be objectionable
Possible complications of operative treatment include:
- Surgical complications not specifically associated with biceps tenodesis, such as pain, bleeding, infection, nerve injury, stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity. All of these are uncommon
- Failed tenodesis, with residual or recurrent defect due to discontinuity of the biceps long head.
When can you return to your sport/activity?
When treated non-operatively, symptoms often resolve quickly and may permit return to even overhead activities within weeks of the rupture. The rate of return depends upon many factors, including arm dominance, demands, sport and presence of associated pathology, such as tears of the rotator cuff.
When undergoing a tenodesis, upper extremity stresses can be initiated at about three to four months, with resumption of overhead activities such as swimming, throwing, tennis and golf closer to the four to six month time frame. Rotator cuff repair adds to this recovery timetable.
How can a biceps tendon tear be prevented?
Because biceps tendon tears are consequent to a load superimposed on pathologic degenerative tissue, prevention is to some degree unavoidable. However, there are certain steps that have value in most athletic undertakings, including:
- Appropriately warm up and stretch before practice or competition.
- Allowing sufficient time for adequate rest and recovery between practices and competition.
- Maintenance of appropriate conditioning:
- Shoulder and elbow flexibility
- Muscle strength and endurance
- Cardiovascular fitness
- Use of proper technique.