Biceps Rupture

Biceps tendonitis, also called bicipital tendonitis, is inflammation in the main tendon that attaches the top of the biceps muscle to the shoulder. The most common cause is overuse from certain types of work or sports activities.

Biceps tendonitis may develop gradually from the effects of wear and tear, or it can happen suddenly from a direct injury. The tendon may also become inflamed in response to other problems in the shoulder, such as rotator cuff tears, impingement, or instability (described below).

This guide will help you understand

• What parts of the shoulder are affected
• The causes of biceps tendonitis
• Ways to treat this problem

The biceps muscle goes from the shoulder to the elbow on the front of the upper arm. Two separate tendons (tendons attach muscles to bones) connect the upper part of the biceps muscle to the shoulder. The upper two tendons of the biceps are called the proximal biceps tendons, because they are closer to the top of the arm.

The main proximal tendon is the long head of the biceps. It connects the biceps muscle to the top of the shoulder socket, the glenoid. It also blends with the cartilage rim around the glenoid, the labrum. The labrum is a rim of soft tissue that turns the flat surface of the glenoid into a deeper socket. This arrangement improves the fit of the ball that fits in the socket, the humeral head.

Beginning at the top of the glenoid, the tendon of the long head of the biceps runs in front of the humeral head. The tendon passes within the bicipital groove of the humerus and is held in place by the transverse humeral ligament. This arrangement keeps the humeral head from sliding too far up or forward within the glenoid.

The short head of the biceps connects on the coracoid process of the scapula (shoulder blade). The coracoid process is a small bony knob just in from the front of the shoulder. The lower biceps tendon is called the distal biceps tendon. The word distal means the tendon is further down the arm. The lower part of the biceps muscle connects to the elbow by this tendon. The muscles forming the short and long heads of the biceps stay separate until just above the elbow, where they unite and connect to the distal biceps tendon.

Tendons are made up of strands of a material called collagen. The collagen strands are lined up in bundles next to each other. Because the collagen strands in tendons are lined up, tendons have high tensile strength. This means they can withstand high forces that pull on both ends of the tendon. When muscles work, they pull on one end of the tendon. The other end of the tendon pulls on the bone, causing the bone to move.

Contracting the biceps muscle can bend the elbow upward. The biceps can also help flex the shoulder, lifting the arm up, a movement called flexion. And the muscle can rotate, or twist, the forearm in a way that points the palm of the hand up. This movement is called supination, which positions the hand as if you were holding a tray.

Related Document: A Patient’s Guide to Shoulder Anatomy

Continuous or repetitive shoulder actions can cause overuse of the biceps tendon. Damaged cells within the tendon don’t have time to recuperate. The cells are unable to repair themselves, leading to tendonitis. This is common in sports or work activities that require frequent and repeated use of the arm, especially when the arm motions are performed overhead. Athletes who throw, swim, or swing a racquet or club are at the greatest risk.

Years of shoulder wear and tear can cause the biceps tendon to become inflamed. Examination of the tissues in these cases commonly shows signs of degeneration. Degeneration in a tendon causes a loss of the normal arrangement of the collagen fibers that join together to form the tendon.

Some of the individual strands of the tendon become jumbled due to degeneration, other fibers break, and the tendon loses strength. When this happens in the biceps tendon, inflammation, or even a rupture of the biceps tendon, may occur.

Related Document: A Patient’s Guide to Rupture of the Biceps Tendon

Biceps tendonitis can happen from a direct injury, such as a fall onto the top of the shoulder. A torn transverse humeral ligament can also lead to biceps tendonitis. (As mentioned earlier, the transverse humeral ligament holds the biceps tendon within the bicipital groove near the top of the humerus.) If this ligament is torn, the biceps tendon is free to jump or slip out of the groove, irritating and eventually inflaming the biceps tendon.

Biceps tendonitis sometimes occurs in response to other shoulder problems, including

• Rotator cuff tears
• Shoulder impingement
• Shoulder instability

Aging adults with rotator cuff tears also commonly end up with biceps tendonitis. When the rotator cuff is torn, the humeral head is free to move too far up and forward in the shoulder socket and can impact the biceps tendon. The damage may begin to weaken the biceps tendon and cause it to become inflamed.

Related Document: A Patient’s Guide to Rotator Cuff Tears

In shoulder impingement, the soft tissues between the humeral head and the top of the shoulder blade (acromion) get pinched or squeezed with certain arm movements.

Related Document: A Patient’s Guide to Shoulder Impingement

Conditions that allow too much movement of the ball within the socket create shoulder instability. When extreme shoulder motions are frequently repeated, such as with throwing or swimming, the soft tissues supporting the ball and socket can eventually get stretched out.

Related Document: A Patient’s Guide to Shoulder Instability

The labrum (the cartilage rim that deepens the glenoid, or shoulder socket) may begin to pull away from its attachment to the glenoid. A shoulder dislocation can also cause the labrum to tear. When the labrum is torn, the humeral head may begin to slip up and forward within the socket. The added movement of the ball within the socket (instability) can cause damage to the nearby biceps tendon, leading to secondary biceps tendonitis.

Related Document: A Patient’s Guide to Labral Tears

Patients generally report the feeling of a deep ache directly in the front and top of the shoulder. The ache may spread down into the main part of the biceps muscle. Pain is usually made worse with overhead activities. Resting the shoulder generally eases pain.

The arm may feel weak with attempts to bend the elbow or when twisting the forearm into supination (palm up). A catching or slipping sensation felt near the top of the biceps muscle may suggest a tear of the transverse humeral ligament.

Dr. Kiritsis will first take a detailed medical history. You will need to answer questions about your shoulder, if you feel pain or weakness, and how this is affecting your regular activities. You’ll also be asked about past shoulder pain or injuries.

The physical exam is often most helpful in diagnosing biceps tendonitis. Your doctor may position your arm to see which movements are painful or weak. Available arm motion is checked. And by feeling the biceps tendon, the doctor can tell if the tendon is tender.

Special tests are done to see if nearby structures are causing problems, such as a tear in the labrum or in the transverse humeral ligament. The doctor checks the shoulder for impingement, instability, or rotator cuff problems.

X-rays are will be obtained at your first visit. An X-ray can show if there are bone spurs or calcium deposits near the tendon. X-rays can also show if there are other problems, such as a fracture. Plain X-rays do not show soft tissues like tendons and will not show biceps tendonitis.

When the shoulder isn’t responding to treatment, magnetic resonance imaging (MRI) scan may also be ordered. An MRI is a special imaging test that uses magnetic waves to create pictures of the shoulder in slices. This test can tell if there are problems in the rotator cuff or labrum.

Arthroscopy is an invasive way to evaluate shoulder pain that isn’t going away. It is not used to first evaluate biceps tendonitis. It may be used for ongoing shoulder problems that haven’t been found in an X-ray or MRI scan. Dr. Kiritsis uses an arthroscope to see inside the joint.

The arthroscope is a thin instrument that has a tiny camera on the end. It can show if there are problems with the rotator cuff, the labrum, or the portion of the biceps tendon that is inside the shoulder joint.  Dr. Kiritsis will typically evaluate the shoulder with an MRI prior to considering an arthroscopy.

Whenever possible, Dr. Kiritsis treats biceps tendonitis without surgery. Treatment usually begins by resting the sore shoulder. The sport or activity that led to the problem is avoided. Resting the shoulder relieves pain and calms inflammation.

Anti-inflammatory medicine may be prescribed to ease pain and to help patients return to normal activity. These medications include common over-the-counter drugs such as ibuprofen.

Dr. Kiritsis may have his patients work with a physical or occupational therapist. Therapists apply treatments to reduce pain and inflammation. When present, conditions causing biceps tendonitis are also addressed. For example, shoulder impingement may require specialized hands-on joint mobilization, along with strengthening of the rotator cuff and shoulder blade muscles. Treating the main cause will normally get rid of the biceps tendonitis. When needed, therapists also evaluate the way you do your work or sports activities to reduce problems of overuse.

In rare instances, an injection of cortisone may be used to try to control pain. Cortisone is a very powerful steroid. However, cortisone is used very sparingly because it can weaken the biceps tendon, and possibly cause it to rupture.

Surgery is reserved for patients who need arm strength, are concerned with cosmetics of the balled-up biceps, or who have pain that won’t go away.

Biceps tenodesis is a surgery to anchor the ruptured end of the biceps tendon back to the bone.  This procedure can be done arthroscopically (with tiny incisions and a camera) or through a larger open incision.  When it’s done arthroscopically, suture anchors are placed adjacent to the tendon in the bicipital groove.  The sutures are passed through the tendon in a locking stitch configuration and tied to secure the tendon to the bone.  This technique is less invasive but not quite as strong as the open procedure.

A common open method, called the subpectoral technique, involves attaching the ruptured end to the upper part of the humerus. A small hole is made by Dr. Kiritsis in the humerus. The end of the tendon is slid into the hole and the sutures are pulled out of a separate drill hole and tied down, securing the tendon into the bone.

Dr. Kiritsis begins by making an incision on the front of the shoulder, just below the axilla (armpit). The overlying muscles are separated so Dr. Kiritsis can locate the damaged end of the biceps tendon. The end of the biceps tendon is prepared by cutting away frayed and degenerated tissue.

A burr is used to form a hole within the humerus adjacent to the pectoralis tendon. The tendon is sutured and a second drill hole is used to pass the sutures through. These are tied down securing the tendon to the bone.

Dr. Kiritsis tests the stability of the attachment by bending and straightening the elbow. When he is satisfied with the repair, the skin incisions are closed, and the shoulder is placed in a protective sling.

In cases where the ruptured biceps tendon is treated nonsurgically, you will need to avoid heavy arm activity for three to four weeks. As the pain and swelling resolve, you should be safe to begin doing more normal activities.

If the tendon is only partially torn, however, recovery takes longer. Patients usually need to rest the shoulder using a protective sling. As symptoms ease, a carefully progressed rehabilitation program under the supervision of a physical or occupational therapist usually follows. This often involves four to six weeks of therapy.

Immediately after surgery, you’ll need to wear your shoulder sling for about four weeks. Dr. Kiritsis prefers to have his patients start a gentle range-of-motion program soon after surgery. When you start therapy, your first few therapy sessions may involve ice and electrical stimulation treatments to help control pain and swelling from the surgery. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasms and pain.

You will gradually start exercises to improve movement in the forearm, elbow, and shoulder. You need to be careful to avoid doing too much, too quickly.

Heavier exercises for the biceps muscle are avoided until at least eight weeks after surgery. Your therapist may begin with light isometric strengthening exercises. These exercises work the biceps muscle without straining the healing tendon.

At about eight to twelve weeks, you start doing more active strengthening. As you progress, your therapist will teach you exercises to strengthen and stabilize the muscles and joints of the elbow and shoulder. Other exercises will work your arm in ways that are similar to your work tasks and sports activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your shoulder.

You may require therapy for twelve weeks. It generally takes three to four months, however, to safely begin doing forceful biceps activity after surgery. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.