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The biceps tendon in the shoulder is composed of two heads: the long head and the short head.
The long head of the biceps tendon (LHBT) originates from the supraglenoid tubercle of the scapula and the superior glenoid labrum within the shoulder joint. It travels through the shoulder joint, exits the joint capsule, and runs through the
bicipital groove (also known as the intertubercular sulcus) of the humerus.
The short head of the biceps tendon originates from the coracoid process of the scapula [Nakata et al, 2011; Erickson et al, 1992; Katsuki et al, 2018].
The LHBT is stabilized by the biceps pulley, a capsuloligamentous complex that includes the superior glenohumeral ligament, the coracohumeral ligament, and the distal attachment of the subscapularis tendon [Nakata et al, 2011].
This complex helps maintain the position of the tendon within the bicipital groove and contributes to the stability of the shoulder joint. Understanding the precise anatomy and course of the LHBT is crucial for diagnosing and managing shoulder pathology, such as biceps tendinitis, SLAP lesions, and biceps tendon instability [Nakata et al, 2011; Erickson et al, 1992].
Biceps tendinopathy refers to a spectrum of disorders affecting the long head of the biceps tendon (LHBT), characterized by pain and dysfunction.
Histologic studies, such as those by Streit et al. (2015), have shown that pain from the biceps brachii tendon is rarely due to inflammation. Instead, the tendon changes are consistent with a chronic degenerative process [Streit et al, 2015].
Histopathologic analyses of the LHBT in patients undergoing tenodesis have demonstrated advanced degenerative changes, including myxoid degeneration, collagen disorganization, and increased vascularization, with minimal evidence ofacute inflammation [Simon et al, 2022].
These findings are consistent with tendinosis, a condition marked by chronic degeneration rather than acute inflammatory changes.The term "tendinopathy" is preferred over "tendinitis" because it more accurately reflects the underlying pathology, which involves a disordered and degenerative healing process rather than inflammation [Kane et al, 2019].
This distinction is important for clinical management, as treatments targeting inflammation, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, may not address the root cause of the pain and dysfunction in tendinopathy.
In summary, biceps tendinopathy is primarily a chronic degenerative condition rather than an inflammatory one, as evidenced by histologic studies showing minimal inflammation and significant degenerative changes in the tendon [Simon et al, 2022].
Distinguishing between rotator cuff tears and biceps tendon tears can be challenging due to overlapping symptoms. However, specific clinical presentations, physical examination findings, and imaging studies can aid in differentiation.
Clinical Presentation:
Rotator Cuff Tears: Typically present with lateral shoulder pain, often woresened by overhead activities and night pain. Patients may report weakness, particularly with arm elevation and external rotation [Jain & Khazzam et al, 2024].
Biceps Tendon Tears: Present with anterior shoulder pain, often described as a deep, throbbing ache. Pain is exacerbated by activities involving shoulder flexion and supination [Churgay, 2009].
Physical Examination:
Rotator Cuff Tears: The physical exam tests to identify rotator cuff tears are different than for biceps tendon pathology. In addition, patients may experience muscle atrophy and weakness in abduction and external rotation are common [Jain & Khazzam et al, 2024].
Biceps Tendon Tears: The physical exam tests to identify biceps tendon pathology are different than for rotator cuff tears. Patients may also experience tenderness over the bicipital groove.
Imaging Studies:
Ultrasound is highly effective for both conditions. For biceps tendinopathy,
ultrasound shows high sensitivity and specificity for detecting full-thickness tears and dislocations. For rotator cuff tears, ultrasound can visualize tendon integrity and muscle atrophy [Courage et al, 2023].
MRI provides detailed images of both the rotator cuff and biceps tendon. MRI is particularly useful for visualizing intra-articular pathology and associated labral tears [Canavan et al, 2024; Alraddadi et al, 2024].
Differential Injections:
Ultrasound-Guided Injections: Diagnostic injections can help localize the source of pain. Anesthetic injections into the subacromial space can relieve pain from rotator cuff pathology, while injections into the bicipital groove can confirm biceps tendon involvement [Churgay, 2009].
Conservative Management
Rest and Activity Modification: Initial treatment for most tendinopathy often includes rest and avoiding activities that exacerbate symptoms, particularly overhead motions [Churgay, 2009; Nho et al, 2010].
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs can help manage pain, although their role is more for symptomatic relief rather than addressing the underlying degenerative changes [Churgay, 2009; Nho et al, 2010].
Physical Therapy: A structured physical therapy program focusing on eccentric exercises has shown consistent effectiveness in managing tendinopathy-related pain and improving function. Eccentric loading exercises are particularly beneficial in promoting tendon healing and reducing pain [Irby et al, 2020; Kane et al, 2019].
Corticosteroid Injections: Ultrasound-guided corticosteroid injections into the biceps tendon sheath can provide short-term pain relief and improve function. These injections are more accurate and cause less discomfort when performed under ultrasound guidance compared to palpation-guided techniques.
A study by Yiannakopoulos et al. compared ultrasound-guided injections to palpation-guided injections for tendinosis of the long head of the biceps tendon. The study found that ultrasound-guided injections were more accurate, with a 100% accuracy rate compared to 68.18% for palpation-guided injections. Additionally, ultrasound-guided injections resulted in lower patient discomfort and faster procedure times, and the ultrasound-guided group demonstrated superior clinical improvement at both time points [Yiannakopoulos et al, 2020].
Platelet Rich Plasma (PRP) Injections: PRP therapy involves injecting a concentrated solution of platelets derived from the patient's own blood into the site of tendon injury. This solution contains several growth factors that promote healing, including platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), and transforming growth factor-beta (TGF-β). PRP shows promise in treating biceps tendon pathology, with evidence supporting its role in reducing pain and improving function.
In a case controlled study by Ashraf Elazab et al. (2021), 52 caese were divided into 2 equal groups and underwent a single ultrasound-guided PRP injection for long head biceps tendinitis compared to a placebo injection with xylocaine (local anesthetic). The authors found a significant improvement in both pain and shoulder function (measured by the Oxford Shoulder Score) following the PRP injection when compared to the control (placebo injection). These findings suggest that PRP can offer effective relief for biceps tendinopathy, especially for patients who have not responded to conservative treatments like physical therapy or anti-inflammatory medications [Ashraf et al, 2021].
Surgical Management
Surgical management options for biceps tendon pathology include biceps tenotomy and tenodesis.
Biceps tenotomy is a surgical procedure is often performed under general anesthesia where the surgeon makes an incision and uses an arthroscope to view the inside of the shoulder joint. The long head of the biceps tendon is then identified and cut to release the tendon from its attachment at the top of the shoulder joint using an arthroscopic shaver or electrocautery device. Any remaining tendon stump is then debrided to prevent impingement or irritation.
Biceps tenotomy is often offered to patients who do not require high levels of arm strength for their daily activities
Tenotomy is associated with a higher incidence of cosmetic deformity, known as the "Popeye sign," due to the retraction of the biceps muscle and bulge of the muscle due to the tendon no longer being anchored to the shoulder.
Some patients may also experience cramping or a slight decrease in arm strength, especially when bending the elbow or turning the palm upward, which could affect day-to-day activities like lifting or twisting [Pozzetti Daou et al, 2021; Frank et al, 2018].
Biceps tenodesis is a surgical procedure under general anesthesia that involves making an incision over the front of the shoulder, and using an arthroscope (small camera) the surgeon detaches the biceps tendon from its attachment inside the shoulder joint. The tendon is then reattached to the upper part of the humerus (the bone of the upper arm) by drilling a hole and using anchors, screws or sutures to secure the tendon in a new position. Once secured, the incision is closed with stitches. Full recovery can take a few months, and following the rehabilitation plan is crucial for a successful outcome.
Like any surgery, biceps tenodesis carries risks, including:
Cramping: Some patients may experience cramping in the biceps muscle after surgery, which can be uncomfortable but is usually temporary. Specific percentages are not well-documented.
Residual Pain: Pain in the biceps groove can persist in some cases, even after successful surgery, occurring in about 10.8% to 12.9% of cases [McCrum et al, 2019].
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