Biceps Tendon Tears

The biceps muscle, running from the elbow up to the shoulder, is unusual because it has 2 tendons that join it to the shoulder bones (hence bi-ceps = two heads). The long head biceps tendon is the main tendon of the biceps muscle, and it attaches to the top of the glenoid (shoulder socket), merging with the cartilaginous rim of the socket (or labrum).  At the top of the humerus, a groove in the bone stops the tendon sliding out of position.  The short head biceps tendon attaches to the knob of bone, called the coracoid process, at the front of the shoulder.  Long head tendon tears normally occur near the end of the tendon close to where it attaches to the labrum ‘rim’ of the shoulder socket.  However as there are two tendons or heads  there is often only a relatively small loss in strength and functionality as the short head biceps tendon will continue to work.

What causes them?

In middle-aged/older patients the tendon most commonly tears or ruptures due to wear and tear, particularly if the patient suffers from another shoulder problem (e.g. subacromial impingement,  rotator cuff tear ) that has already weakened the tendon.  In younger athletes they can be caused by weightlifting or a fall onto the arm when it is outstretched.

How do they feel?

With a tear, the front of your shoulder will be painful and your arm may feel weak. You may be unable to raise your arm with the palm of your hand pointing upwards.

If the tendon breaks, you may hear or feel a snap in the top of your arm, and then you will feel a pain which will subside after a while.  Indeed, patients who have had pain from a damaged tendon find the pain goes away when the tendon ruptures.  Your upper arm may also be bruised afterwards and because the torn tendon can no longer keep the muscle taut, you may also notice a bulge in the upper arm.

Diagnosis

Your doctor will ask you about your medical history and will carry out a physical examination to see which movements cause pain, and he will feel the tendon itself. If the exam is inconclusive, he may order an MRI (magnetic resonance imaging) scan which will clearly show a tear or rupture.   Sometimes your doctor may want to see an X-ray of your shoulder to check if there are any bone spurs that could have damaged the tendon.

 
Treatment – conservative

Your doctor may ask you to wear a sling to rest your shoulder, to apply ice-packs to soothe any pain or inflammation, and prescribe anti-inflammatory medication.  He may suggest that you follow a physiotherapy programme to show you how to minimise the strain on your biceps muscle and on the remaining short head tendon, and to build up the other muscles so they can help do the work of the biceps.  In the case of a partial tear, he may also prescribe a course of shock-wave therapy treatments.

Treatment – surgical

– Arthroscopic Debridement: through two small incisions, and with the aid of an arthroscope, the surgeon will clean up the tear, trimming the frayed edges of the tendon, and removing loose particles of tissue.

– Arthroscopic Tenotomy: this procedure is used for patients who have either a significant tear, or a subluxation (the tendon has moved out of its groove in the top of the humerus).

Through two small incisions, and with the aid of an arthroscope, the surgeon will cut the long head tendon.  As the tendon heals, it will reattach lower down the humerus.

– Arthroscopic Biceps tenodesis: this procedure is performed on younger patients who have either a total rupture of the tendon, or a subluxation (the tendon has moved out of its groove in the top of the humerus).

Your surgeon will make 2 or 3 small incisions on the top of your shoulder through which he will insert a fibre-optic camera and the surgical instruments he needs to use.  He will make a small hole in the humerus, and insert the torn end of the tendon, anchoring it to the bone. 

In certain cases, this procedure may be performed in ‘open’ surgery, i.e. through a larger incision (4-5cm) on the top of the shoulder, rather than arthroscopically.  The rehabilitation will take longer as more of the surrounding tissues will have been disturbed.

Rehabilitation after surgery

Arthroscopic debridement: you should wear a sling for the first few days after the operation to rest your shoulder, and you will be given physiotherapy exercises to rebuild your muscles and restore a full range of movement.

Tenotomy: you will need to wear a sling for about 3 weeks after surgery, although you will start straight away on a physiotherapy programme of mostly passive exercises (the physiotherapist moves your arm for you).  After 3 weeks you can start active movements during your physiotherapy sessions, stretching, regaining your range of movement and very gradually re-building your muscles.

Biceps tenodesis: you will need to wear a sling for the first 4 weeks after surgery.  Your doctor will give you a 6-8 week physiotherapy programme which will first focus on controlling post-operative pain and swelling.  Then you will gradually start moving your arm to get back your range of movement, and begin light muscle strengthening exercises.

When will I be back to normal?

Arthroscopic debridement: depending on the type of work you do, you should be able to resume work between 2-7 days after the operation, and driving after a week. Normal sporting activity can be resumed after 2 weeks.

Tenotomy: you can return to office-work after a week, although if you do manual work you will have to wait 8 weeks. You should be able to drive after 3 weeks.  You can start doing gentle sporting activity again at 6 weeks, although contact sports should be avoided for at least 6 months after surgery.

Biceps tenodesis: you should be able to start driving again after 2 weeks, and return to office work after 1-2 weeks.  Manual workers should wait 6 weeks before resuming their normal activity.  Gentle sporting activity can be started at 6-9 weeks, although it will take 3-4 months before you can return to contact sports.