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Biceps Tendon Pain: A Popular Diagnosis Loaded with Decades of Controversy

biceps tendon pain

Biceps tendon pain treatment

Biceps tendon pain, particularly the long head of the biceps at the shoulder, is a very popular diagnosis these days.  This diagnosis is also followed by an increasingly common recommendation to perform a surgical procedure called a biceps tenodesis, where the portion of the biceps tendon inside the shoulder joint is removed while stabilizing the origin of the biceps tendon elsewhere, along its anatomic course in the bicipital groove (proximal or distal) or moving it to another location like the coracoid process adjacent to the short head biceps origin.  Although we have treated thousands of patients with biceps tendon pain (pathology), the incidence of patients with isolated pathology of the biceps tendon in my practice is exceedingly rare.  In this article, we hope to help sort through the controversy of not only the diagnosis of isolated biceps pathology, but also the best method of treatment, finally reviewing our preferred technique for addressing biceps tendon pathology.

DIAGNOSIS

Often the diagnosis of biceps tendon pain is made based on tenderness to palpation at the anterior shoulder or at the bicipital groove.  As we reported previously, palpation can be highly accurate for rotator cuff tears, but while the RENT test has been independently cited as having a high quality of diagnostic accuracy for rotator cuff tears (Br J Sports Med 2008; 42:80–92.), no such physical examination maneuver or test has been supported for the diagnosis of biceps tendon pathology.  In Physical Examination for Partial Biceps Tendon Tears, AJSM. Vol. 35, No. 8, 2007, Gill et al. evaluated 847 patients with a variety of shoulder pathologies who underwent arthroscopy for the accuracy of physical examination techniques to predict the presence of biceps tendon pathology.  Overall, tenderness on palpation in the region of the biceps had a sensitivity of 53%, a specificity of 54%, and an accuracy of 54%.  The authors concluded, “Our study shows that no single physical examination test can accurately predict the presence of a partial tear of the long head of the biceps tendon and highlights the difficulty of assessing the role of the biceps tendon in pain syndromes of the shoulder. One confounding factor is that there is no known pain pattern specific for the biceps tendon. Although biceps tendon pain can radiate down the front of the shoulder, pain into the front of the shoulder can be secondary to a variety of causes, including rotator cuff injury.”  Of further interest, as in our own experience, all patients with partial biceps tendon tears also had other lesions.

ANATOMY, PATHOLOGY, AND FUNCTION

The biceps tendon long head has several unique features.  Along with being part of a two joint muscle (the biceps spans the shoulder and elbow joints), the biceps long head tendon is intra-articular (within the joint) but extrasynovial, meaning it is contained within a sheath formed by the continuation of the synovial lining of the joint capsule.  This means that the segment of the tendon within the joint from approximately 1-3cm distal to its origin is a relatively hypovascular region. As with other tendons that are part of two joint muscles (Achilles tendon, Iliotibial band, quadriceps tendon, etc.) the biceps tendon is subject to potentially greater stresses.  The elastic range of strain for tendons is less than 4% and microscopic failure occurs beyond 4% strain.  Beyond 8-10% strain, macroscopic failure occurs and complete failure can occur rapidly thereafter.  Both the amount and rate of loading can play a role in tendon injury.  The highest risk of rupture occurs when tension is applied quickly and obliquely, and the highest forces are seen during eccentric muscle contraction.

The biceps tendon itself, like other tendons, does not have many nerve fibers within the main body of the tendon. The majority of the nerve supply forms a sheath around the tendon as well as supplying specialized mechanoreceptors (Golgi Tendon Organs) to the muscle tendon junction.  Along with helping coordinated muscle activity, position sense, protective inhibition and stress relaxation, these fibers also help transmit biceps tendon pain (glutamate, substance P, etc.).

The oxygen consumption of tendons and ligaments is also 7.5 times lower than that of skeletal muscles.  Although these adaptations are essential to carry loads and maintain tension for long periods without ischemia and necrosis, the low metabolic rate also means a very slow rate of healing after injury.

All of these factors help us better understand that the biceps tendon, along with other tendons as well, can be injured by multiple mechanisms-acute, chronic, intrinsic, extrinsic, micro trauma, and macro trauma-and commonly a combination of mechanisms, acute on chronic for example.   With any injury, the intrinsic ability of the tendon to heal is tested.  Although the term biceps “tendonitis” and “tendinitis” are often used, inflammation of the biceps tendon itself is rarely seen, as the inflammatory changes typically occur at the biceps tendon sheath.  As with other tendons, the more correct term for biceps tendon injury should be biceps tendinopathy, meaning pathologic change of the biceps tendon.  The exact mechanism and process for biceps tendinopathy still remains unclear, with many possible-contributing factors.  Often, degenerative changes of the rotator cuff also accompany biceps tendon degeneration with mucoid degeneration, fibrocartilaginous metaplasia accompanied by calcium deposition, and amyloid degeneration all observed.

Unfortunately, the degenerative tissue that forms in response to injury does not have the same biomechanical profile of normal tendons, and more than likely a downward spiral of increasing stress and strain on the remaining normal tendon fibers results in propagation of injury with progressive deterioration leading to tendon failure.

The function of the biceps tendon long head is still highly debated and not entirely understood.  Shoulder function and movement requires a highly complex and coordinated chain of events, which also means that with so many steps involved in the process, the causes for injury and pain can be many and varied.  For instance, one study, comparing professional to amateur pitchers, found that amateurs required considerably more biceps activity to accelerate and decelerate the arm, while professionals were able to selectively recruit the subscapularis portion of the rotator cuff for this purpose.  Possibly, those with the greatest inherent skill or control in the throwing motion are able to lessen the demands on the biceps tendon (AJSM 1987 Nov-Dec;15(6):586-90).

Along with biceps tendon pain and tendinopathy, a lot of work has also been done on the origin of the biceps tendon long head.  There is considerable variability in the origin of the biceps tendon long head, with reported origins from the supraglenoid tubercle, superior labrum, posterior labrum, and rotator cuff, have been reported.  Combinations of these have also been reported.  More information about superior labrum anterior posterior (SLAP) lesions is available here (http://www.theshouldercenter.com/labrum-tear-slap-lesion/).

Consistent with the “circle concept” of the shoulder, we find biceps tendon long head pathology to often coexist with all the other maladies and diagnoses that afflict the shoulder.

TREATMENT

Treatment of biceps tendinopathy is also controversial.  For the biceps tendon long head, itself, recommendations include biceps tenotomy and biceps tenodesis.  There is also considerable controversy regarding the need to evaluate and address concurrent shoulder pathology at the same time.  This recent article from USA Today helps highlight the debate at this shoulder surgery article at USA Today. Based on our belief that the shoulder function is indeed complex and not entirely understood, we focus on anatomic restoration and repair of all concurrent pathology.  To provide some historical basis and support for the anatomic approach, a long-term review performed at the Mayo Clinic (Becker et al. JBJS. 1989; 71: 376-381) found that isolated biceps tenodesis although advocated for more than fifty years, resulted in disappointing results with longer follow-up.

A biceps tenotomy involves releasing the biceps tendon long head from its origin inside the shoulder joint.  The tendon then retracts for a variable distance and heals at this variable distal location.

A biceps tenodesis involves releasing the biceps tendon long head from its origin inside the shoulder joint, followed by fixation of the tendon.  The fixation method and location can be highly variable and are of significant debate.  Several popular options include-soft tissue tenodesis (suturing the biceps tendon long head to the rotator cuff or biceps pulley), suture anchor fixation and interference screw fixation.  Biceps tenodesis has also been promoted proximally within the bicipital groove, distally at the exit of the bicipital groove, more distally at the pectoralis major insertion, and at the coracoid process next to the biceps short head origin.

A recent study by Wittstein et al. (AJSM. 2010) compared biceps tenotomy with biceps tenodesis, and found that the patients with a biceps tenotomy had a higher incidence of a “Popeye deformity” and reduced supination strength with all other parameters including patient satisfaction similar between the two groups.

OUR APPROACH

The “Popeye deformity” has been reported with both biceps tenodesis and tenotomy and most agree that this is likely more reflective of the level of core degeneration and fraying of the biceps tendon long head rather than the strength of fixation.  It is important to honor the biologic time required for tendon healing before initiating stressful activities.  With this in mind, we attempt to preserve the anatomic course of the biceps tendon long head in the hopes of helping to preserve as much of the neuromuscular and proprioceptive feedback role of the biceps tendon long head while removing the diseased and hypovascular portion of the tendon from within the shoulder joint.  For highly diseased and frayed tendons with little remaining structural capacity, we perform a biceps tenotomy at its origin, which typically results in the migration of the tendon to the level of the bicipital groove.

For tendons with residual structural capacity, we perform a soft tissue biceps tenodesis.  Our technique for soft tissue biceps tenodesis is termed the arthroscopic locking lasso rack hitch biceps tenodesis technique.  The biceps tendon is sutured to the rotator cuff (subscapularis, supraspinatus) and/or the biceps reflection pulley based on the unique circumstances involved in each case.

As noted at the beginning of our discussion, in our hands, biceps tendon pathology is most often incidental to other treatable pathology within the shoulder so it is important to have a reliable, minimally invasive, and anatomic technique that does not require a considerable amount of operative time and additional implants.  Our technique also avoids the possible complications related to open surgery, avoids the cost of additional implants, and does not interfere with MRI or CT scans.

In summary, biceps tendon pain is often the harbinger of additional pathology and we recommend a thoughtful, detailed, and comprehensive approach to the evaluation of patients with anterior shoulder pain and biceps tendon pain.

Comments

  1. ken welsh says:

    I just read the biceps pain treatment article. Is there such a thing as a triceps pain, tear or other problem?

    Also I have Anthem major med and would be paying for an evaluation. What would that cost. I have x-rays and an MRI.

    Thank You
    Ken Welsh

    • Ken,
      Thanks for your comments and question. Yes triceps pain can be caused by many possible sources aside from a strain or tear. A detailed evaluation with a shoulder specialist can help you establish the correct diagnosis and get you on the road to recovery faster. Please call us at (317) 802-9686 if you would like to schedule an evaluation.
      Best regards,
      The Shoulder Center Team

  2. I fell back and landed on point of shoulder and ended up with ac grade 3 injury which was conservatively treated. I still have pain in tendon along top of shoulder blade and it clicks a year later is it possible tendon was damaged as well.

    • Gary,
      Thanks for your comment and question. In our experience, the AC joint area can experience pain that is referred from several other areas. The vast majority of patients we treat surgically for persistent symptoms and pain following a high grade AC dislocation, have other contributing pathology that needs to be addressed as well- SLAP lesion, rotator cuff tear, unstable shoulder, etc. If you are having persistent symptoms, we recommend you consider an evaluation with shoulder specialist.
      Best regards,
      The Shoulder Center Team

  3. Deon Valentyn says:

    Hi, I had arthoscopic surgery done on my left shoulder for SLAP tear (dominant hand). I was told to walk with sling for at least 6 weeks and have physiotherapy to help with recovery. This is the 6th week after surgery and I don’t think I am even close to have physio. I still experience the same dull pain and discomfort in shoulder and also into my bicep. My question is, “is it normal?”

    • Deon,
      Thanks for your comment and question. It is difficult for us to comment on your specific surgical procedure and we would recommend discussing the expected course of recovery, etc. with your surgeon. As a general rule, however, it takes approximately 3 months for primary healing of soft tissue repairs in the shoulder and we typically have our patients avoid any stress to the repair during the first three months, primarily focusing on restoring motion in the supine (lying down) position. We hope you find this information to be helpful and we wish you a speedy recovery.
      Best regards,
      The Shoulder Center Team

  4. Jon Cornia says:

    Hi,
    6 months ago I had arthroscopic surgery to have my rotator cuff repaired, the surgeon said that I would also possibly need the tendon reattached. When inspecting the tendon during surgery, he said it looked fine,(I was unconscious, so could not argue the point!) Now with a Post op MRI and a persistent pain in the bicep, he has determined that the tendon has interior deterioration. He gave me a cortisone shot, and said if it does not get better he will have to operate again. Does this increase my chances of a rupture? How long should I wait to see if it gets better?
    Thanks,
    Jon

  5. I had an MRI done and the results showed a partial proximal bicep tendon tear (split in half, confirmed by two different Dr’s. A bicep tenodesis was recommended. My question being and I know it may vary from one person to another; can a partial bicep tendo tear cause pain high on the chest in the coracoid process area as well as the shoulder blade? I fell like those whole upper left side of my body hurts and differs from one day to the next but the pain near the coracoid process is extremely irritating. Thanks

    • As I mentioned in the blog post, I have never performed just a biceps tenodesis and believe it is universally a problem that happens secondary to some other shoulder pathology. It is important to perform a thorough physical examination and also if you do decide to proceed with an operation, make sure and pick someone that is fully prepared to address any pathology comfortably. Your description of pain is concerning for more than just the biceps tendon as the symptom generator. Hope that helps. Good luck!
      Dr. Agrawal

  6. george griffin says:

    I had a SLAP repair three years ago, along with rotator cuff repair. I have had a dull aching pain ever since. The pain is mainly in the front part of my shoulder, but aches all over. It gets worse when I do activity and even aches when I play my acoustic guitar. I was 50 when I had the SLAP repair. Is this common for someone to present with lingering pain after that surgery? I had a doctor mention something about a tenodesis and subscabular ligament release.

    • Dear George Griffin,
      Thanks for your inquiry. From the information you provided, I don’t believe we have a clear diagnosis and cause for your persistent difficulty yet. While I certainly tend to combine a biceps tenodesis with a SLAP repair to help minimize the risk of stiffness, pain, and recurrent tear in a situation like the one you describe, without a detailed evaluation and workup, I can’t provide you with more guidance. We perform these procedures to help patients with pain and debility so no, I would not classify your clinical difficulties as the standard expectation after shoulder surgery.
      Best regards,
      Vivek Agrawal, MD

  7. Graeme Reed says:

    Hi could you please offer some information to this injury that has been diagnosed via MRI with ink injection, longitudinal split tear long head biceps injury, have already had right shoulder long head biceps tear repaired with rotator cuff as well. Am wondering what procedure is used for this type of repair ie is it the same as tear repair in that they reattach tendon into humeral groove??

    • Dear Graeme Reed,
      Thanks for your question. It is difficult for me to provide you specific information on your current MRI arthrogram reading as we need a clear indication and impression of what symptoms and recurrent injury you have suffered. Also, you mentioned that you have had a rotator cuff repair and biceps tear repaired previously so the MRI findings currently may represent post surgical change vs. new injury. Also, if you read the blog article, you may already know that we typically find patients to have associated labrum or rotator cuff issues and the biceps is almost never the only symptom generator. Certainly if your question is regarding biceps tenodesis as part of the treatment there are many methods of performing this and your surgeon should be able to discuss the preferred method and reasons in their hands with you.
      Best regards,
      Vivek Agrawal, MD

  8. Graeme Reed says:

    Thanks for reply.
    Sorry didn’t make clear that I have previously had Long head biceps repair, rotator cuff & slap tear repair on right shoulder. My query is for my left shoulder that was imaged at the same time through MRI with ink injection result,
    ” high grade partial thickness articular surface tear of the anterior supraspinatis tendon, longitudinal split tear of the long head biceps tendon, subscabularis tendinopathy and probable small partial thickness tear, fluid is seen within the subacromial bursa suggesting subacromial bursitis, no contrast has extended into the subacromial bursa.”
    I found it difficult to communicate with surgeon and he was not been forthcoming with a lot of information suffice to say am in the process of finding alternate surgeon to do this proceedure and am looking for as much information as possible to know whats going to happen during surgery.
    At times the pain is unbearable down the front of shoulder/ arm to the point i cannot lift, no weight, forward of body. So i need to get something done as it will interfere with my work as fabricator.
    Is the proceedure similar as long head biceps tear repair, or do you use different proceedure, I have seen where longitudinal split has been sutured along split for repair and would recovery be similar to tear repair??
    Once again thank you for reply.

    • Dear Graeme Reed,
      From the information you provided you may require a similar procedure on this shoulder as you had on the other…rotator cuff repair, SLAP lesion repair, and biceps tenodesis but it is difficult for me to give you clear guidance without further evaluation. You may consider a second opinion if you are not comfortable with what you are hearing currently before moving ahead. Remember, it takes the same time for healing whether one or multiple things are repaired so don’t fall into the trap of opting for a lesser procedure rather than comprehensively addressing the problem the first time. Pick a surgeon that routinely and comfortably handles all this and more.
      Good luck!
      Dr. Agrawal

  9. What is the general difference in cost between biceps tenotomy and tenodesis?

  10. Thank you for this informative article.

    I have had an MRI which has found “mild atrophic thinning of the long head of the bicep” along with tendonitis in the supra and infraspinitus, and higher levels of fluid in the bursa. The pain I feel daily in long head of the bicep feels sharp and is different than the duller, diffused pain of the bursitis/tendonitis. Surgery has not been recommended by my doctor but it hasn’t been made clear. What do you think?

    • Dear George,
      Thanks for your comment. You can learn more about shoulder pain here:
      I don’t have enough information from your comment to be able to establish a clear diagnosis and source for your shoulder pain. You may consider getting a second opinion with an experienced shoulder specialist to establish a clear diagnosis and then more comfortably be able to evaluate the various treatment options.
      Best regards,
      Dr. Agrawal

  11. I had left shoulder rotator cuff, and tendon repair surgery 11 years ago, now my shoulder hurts all along the area of the clavicle, and down into my shoulder, i have a very painful pinching feeling along the clavicle area, and am swollen all accross the area. My shoulder is a little subluxed, and have tendon pain radiating to my elbow. I have several lumps along the clavicle area, they are deep inside and i constantly massage them, they are quite painful also. I saw an orthopedic doctor yesterday, he diagnosed a biceps tendon problem, possibly a torn rotator cuff, and i am going for physical therapy. I really need relief for the very intense and painful pinching, burning under the clavicle area, your thoughts are apptrciated.I am a 58 year old female.

    • Debbie,
      Thanks for your post. Without a detailed in person examination and evaluation it is difficult to provide you with a clear diagnosis and path to follow for treatment. If you don’t find that physical therapy has helped your condition, you may consider getting a second opinion with a shoulder specialist.
      Best regards,
      Vivek Agrawal, MD

Trackbacks

  1. […] subscapularis also plays a leading role in stability of the biceps tendon as the biceps tendon splits the posterior portion of the rotator cuff (supraspinatus, […]

  2. […] with biceps tenodesis shown in the upper RIGHT slide because this removes the potential for the biceps pulling the labrum off again and also avoid the issue of scarring and further tearing of the biceps […]

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