Biceps Tendon Tears and Biceps Instability

What are Biceps tendon tears?

Biceps tendon tears or instability of the long head of the biceps tendon in the bicipital grove can result in pain in the front of the shoulder.  Biceps tendon tears can occur from repetitive trauma such as throwing, overuse, or from an injury. Many of these tears are partial tears of the tendon and may be difficult to diagnose. They may occur inside the shoulder joint or outside the joint along the front of the arm.

Partial tear of Long Head Biceps Tendon (black arrow shows tear as the tendon is pulled into the joint). View is from the back of the shoulder.

Biceps tendon tears are commonly associated with rotator cuff tears. A complete tear of the biceps tendon will sometimes result in a "Popeye" muscle deformity and may lead to improvement of pain from a previous partial tear. When there is instability of the biceps tendon, there may be popping noted in the front of the shoulder associated with pain along the biceps. When the biceps tendon is torn or is unstable in its grove, it will not heal or improve on its own.

Treatment of Biceps Tears

Treatment options include leaving it alone, a cortisone injection, a biceps tenotomy, or a biceps tenodesis. Leaving it alone is reasonable if it doesn’t cause too much pain or impairment in function.

Tenotomy

A tenotomy is a release of the biceps tendon from its attachment to the labrum. This is done for sedentary patients and provides excellent pain relief. It usually results in a deformity of the biceps muscle that may have the appearance of a “Popeye” muscle. This may cause some cramping or fatigue of the biceps with repetitive use.

Tenodesis

A Tenodesis is done for active patients. This is when the tendon is attached to the humerus (arm bone) or rotator cuff after it is released from the labrum. My preference is to attach it to the humerus below the humeral head (ball part of the shoulder joint). This is often done with an absorbable screw or may be done with suture anchors or sutures through bone. It can be done arthroscopically or with a small incision. The surgery is done as an outpatient procedure.

Socket created in the humerus for biceps Tenodesis

Biceps tendon has been released from its attachment, suture placed in the end, and it is ready to place in the socket in the humerus

Biceps Tenodesis completed with bioabsorbable screw holding the biceps tendon in the socket

 

Rehabilitation of Biceps Injuries

If a tenotomy is done, a sling is worn for several days to a week based on comfort. When a tenodesis is performed, a sling is worn for four weeks and forceful forearm rotation or elbow flexion are avoided for eight weeks. Physical therapy is started one week after surgery.  Return to unrestricted activity is approximately four months.