Anatomy of Biceps muscle:
Biceps is a large muscle that lies below the skin of upper arm between shoulder and elbow. The muscle originates from two places, the long head from the shoulder joint (supra-glenoid tubercle) and the short head from shoulder blade (coracoid). The two heads join in the upper arm and form the muscle bulk. The muscle crosses both shoulder and elbow joints and attaches to the upper forearm (radial tuberosity). Biceps helps in bending (flexion) the elbow and rotating the forearm (supination- turning palm upwards).
What is biceps tendinitis or tendinopathy?
Bicep tendinitis is the condition of the biceps tendon in which its long head is inflamed or irritated. It is one of the common causes of anterior shoulder pain due to its location (groove in upper arm bone) and function. Long heads of Biceps tendinitis (LHBT) or biceps tendinopathy is caused by sudden injury to the tendon or overuse as done in repetitive overhead actions in sports like swimming, baseball or tennis, martial arts or degeneration during the normal ageing process. Only 5% of the patients has isolated biceps tendon dysfunction and the remaining 95% is often associated with rotator cuff tears, SLAP lesions, shoulder arthritis, shoulder instability or impingement syndrome. Most cases are seen in young and middle-aged patients (18-35yrs) and are often caused secondarily to scapular instability, shoulder ligamentous instability, anterior capsule laxity, or posterior capsule tightness or rotator cuff tears.
What are the symptoms of the Long head of biceps tendinitis?
The patients usually present with deep throbbing pain and tenderness at the anterior (front top) portion of the shoulder. The pain usually radiates down the arm in the outer side. It is aggravated when the upper arm is used to lift anything overhead or perform any activity. The pain usually prevents the patients to lie on the affected side and could wake them from sleep. It is relieved by rest and pain killers. A snapping sound is sometimes heard with the movement of the arm and is usually due to the tendon slipping from the groove. You may feel weak when you bend or twist your arm. Studies have shown that with torn LHBT, you may lose 21% of supination strength and 8% of elbow flexion strength. This loss of strength is debated in the literature and is hardly noticed in chronic tear.
How is it diagnosed?
It is diagnosed after evaluation of your complete medical history, physical examination, special tests (speed test, Yergason test) and reports of X-ray and MRI scan. X-ray does not reveal your problems with biceps tendon, but it may detect other associated ailments related to the bones. MRI scan or ultrasound can show affections of soft tissues like bicep tendon in detail.
What happens if nothing is done?
If it is left untreated, the tendon and its sheath may get inflamed leading to tenosynovitis and may also result in rupture or complete tear of the tendon (Popeye bulge in lower arm). The inflammation could spread to the shoulder joint resulting in marked loss of range of motion of the shoulder, leading to a condition called frozen shoulder. Besides the associated shoulder pathologies can worsen and lead to shoulder dysfunction.
How is it treated?
It is treated both conservatively and surgically. The conservative treatment involves rest, ice application, painkillers, anti-inflammatory medicines, steroid injections and physiotherapy.
Surgery is indicated in
- Selected cases of long head of Biceps rupture
- Severe biceps tendinopathy
- Symptomatic partial or full-thickness biceps tendon tears
- Medial subluxation of tendon
- Associated pathology – cuff tears, recalcitrant impingement syndrome, SLAP tear etc
What are the non-operative treatments?
The non-surgical or conservative methods are the first line of treatment. It includes-
- Rest- resting the shoulder is very necessary for treatment of biceps tendinitis as it enables faster healing process. You should also modify your activities by avoiding repetitive overhead activities.
- Ice packs- application of ice packs 20-30 minutes two to three times a day is beneficial to relieve pain and swelling.
- Medicines- painkillers such as paracetamol and codeine are given to relieve pain. Anti-inflammatory medicines such as ibuprofen and aspirin are prescribed to reduce the pain and inflammation of the tendon.
- Physical therapy- physical therapy is important for restoration of range of motion and strength of the shoulder joint. It is started with mild exercises of wrist, fingers, and elbow and pendulum exercises for the shoulder. The exercises are performed with arm below the shoulder level. Then, these exercises are gradually progressed to strenuous exercises under the supervision of a physiotherapist.
- Steroid injections- steroids like cortisone injections are injected in to the tendon sheath to relieve pain. However, its effect could be temporary and it can weaken the tendon and can even cause a tear if not given cautiously.
What does the operation involve?
The surgical operation is performed in patients not responding to conservative treatment and those with associated shoulder pathology. The procedure is performed with a key hole (arthroscope) and the tendon is assessed in the shoulder joint for any tear and associated pathology.
The main goal of the operation is pain relief and in selective cases to reattach the tendon to the upper arm bone.
- The operation is conducted as a day case under general/local anaesthesia, 2-3 small 1cm cuts are made a tiny camera (arthroscope) is inserted through the cut to locate and assess the tendon
- Biceps tenotomy: It involves cutting of tendon from its origin inside the shoulder joint. Studies have shown promising results with 95-100% pain relief, 90% patients return to pre-injury level of sports and 97% preinjury level of work. However, 45% patients demonstrate Popeye deformity (mainly cosmetic) and 8% cramp like pain. 1 in 30 Biceps tenotomy patients might end up with unacceptable Popeye deformity. This is suitable in patients who want relief of pain and quick return to activities and sports.
- Biceps tenodesis: The inflamed/damaged part of the tendon is removed from the shoulder joint and the proximal cut end delivered through a 2cm cut in the front of the shoulder. After trimming it to appropriate length, it is reattached to upper part of arm bone with anchors. This is suitable in body builders, young labourers and those worried about cosmetic appearance. Post-operatively the patients will need prolonged rehabilitation and restrictions till the tendon heals to the bone.
- The surgical time is usually 1-2hrs and a majority of the patients go home the same day usually after 10 hours of operation. The associated pathologies if found are addressed at the same time.
What happens after surgery?
- The effect of local anaesthesia ends in 4- 10 hours after surgery. The patients are encouraged to take painkillers before they can experience pain usually for 48 hours. In this way, many patients do not report pain.
- The patient is discharged on the same day and advised to take rest and modify his activities based on the procedure. A sling is applied for 2 to 6 weeks to support healing by immobilization.
- Before discharge, the patient is taught set of gentle exercises of the shoulder. These exercises can be started from the day one after the surgery. These exercises are important to reduce stiffness and pain and restore strength and normal range of motion of the shoulder and arm.
- Light activities like using a keyboard or writing are allowed if they don’t cause excessive pain or discomfort.
- The patient is reviewed again after 2 weeks for the check of wound and physiotherapy.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
- You could start a gentle range of movement (ROM) exercises at 3 weeks and progress to more strenuous activities (swimming, driving, lightweights in gym etc) around six weeks. This will be guided by your surgeon. Physical therapy plays an important role in returning back to the normal activities and its vital to work with the physiotherapists to get full function back in your shoulder.
Are there any risks?
- Repair failure
- Injury to radial nerve
- Frozen shoulder
- Recurrence of symptoms
- Injury to blood vessels, nerve and tendons.
- Cramps in Biceps muscle
- Popeye deformity
What are the results of the operation?
Most patients report good pain relief and regain full function after the surgery. The outcome is more predictable in the author’s experience.
When can I return to driving and work?
This ranges from few days in patients who had tenotomy vs few weeks/months in tenodesis. Your surgeon can guide you for this.
The long head of biceps that originate from the shoulder joint is usually inflamed/damaged in the groove of humeral head.