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Proximal Biceps Tendon Injuries

From WikiSM

Other Names

  • Biceps tendinitis
  • Biceps tendonitis
  • Proximal Biceps Tendinitis
  • Biceps Tendinopathy
  • Proximal Biceps Tendon Tear
  • Long Head of Biceps Tendon (LHBT) Pathology
  • Proximal Biceps Tendon Pathology
  • Biceps Tendon Disorder (Proximal)
  • Anterior Shoulder Biceps Pathology
  • Biceps Anchor Pathology
  • Biceps tendon subluxation
  • Biceps tendon dislocation

Background

  • This page refers to proximal injuries to the Biceps Brachii including tendinopathies, instability and tears

History

  • Injuries referenced as early as the 17th century[1]
  • the first reported case of a long head of the biceps brachii tendon dislocation was in 1694 by William Cowper[2]

Epidemiology

  • Tendonitis
    • Primary tendonitis makes up about 5% of proximal biceps pathology
    • 90% of rotator cuff tears have concomitant proximal biceps tendonitis[3]
  • Instability
    • Up to 45% of patients undergoing arthroscopic rotator cuff repair have biceps tendon instability[4]

Pathophysiology

Rupture of long head of the biceps tendon
Anatomy illustration of the biceps brachii
Photographs of a 70-year-old man with biceps tendon rupture. (A) Bilateral comparison with elbow flexion shows hump formation on the right side caused by bulging of the biceps muscle because of proximal rupture, compared with the intact biceps on the contralateral side. Panels (B) and (C) show close-up photographs of the bulging right and normal left biceps muscles, respectively[5]
Overview of bicipital groove anatomy. Line A marks the separation between Zones 1 and 2 as described by Taylor et al. Line B marks the separation between Zones 2 and 3, where the functional bottleneck is located. 1. Supra pectoral tenodesis site (using the supraspinatus anchor); 2. Supra pectoral tenodesis site within the groove; 3. Subpectoral tenodesis site. Right side, anterior view[6]
Tendonitis of the long head of the biceps tendon

General

  • Proximal biceps tendon injuries encompass a spectrum of pathology which includes tendinitis, degenerative tendinosis and tears
  • These often occur in conjunction with other pathology like rotator cuff tears and SLAP lesions
  • Patients typically complain of deep, throbbing anterior shoulder pain exacerbated by repetitive overhead motion
  • Diagnosis can be challenging and involves both MRI and ultrasound
  • Treatment is generally conservative, with surgical intervention considered for specific patients and pathology

Tendonitis

  • General
    • Inflammation typically occurs at the biceptal groove of the Humerus
    • Progresses to a tendinosis as time progresses
  • Primary is uncommon, frequently secondary[7]
    • Etiology for primary is not well understood
    • Seen in younger overhead athletes during late cocking phase (maximum abduction, external rotation) with eccentric contraction
  • Secondary is far more common

Instability

  • Spectrum ranges from subluxation to dislocation
  • Stabilized by rotator interval over the groove, which function as a pulley system to maintain the tendon within the bicipital groove
  • Subluxation associated with injuries to the rotator cuff and more specifically the Subscapularis muscle
  • Dislocation occurs deep to the subscapularis muscle

Rupture

  • Involves the long head of the biceps tendon (LHBT)
  • Most commonly occurring at its attachment to the superior glenoid tubercle and labrum
  • Highly associated with rotator cuff pathology
    • Up to 93% of patients showing evidence of concomitant rotator cuff disease[8]
  • In older adults, typically associated with degenerative changes
  • Less commonly in younger patients, traumatic ruptures can occur during weightlifting or high energy activities[9]
  • Most commonly occurs in a hypovascular zone located 1.2-3 cm from the tendon origin[10]
    • Extending from the glenohumeral joint to the proximal bicipital groove
    • Where reduced arterial supply contributes to tendon weaknes

Anatomy of the Biceps Brachii

    • Long head originates from supraglenoid tubercle and superior Glenoid Labrum
  • Bicipital Groove of the Humerus
    • Anatomic landmark between greater and lesser tuberosities
    • Serves as a critical location of proximal biceps stability
  • Tendo-ligamentous sling overlies the long head in the groove
  • Function
    • Role as a passive, possibly dynamic, stabilizer of shoulder

Associated Injuries

Risk Factors

  • Sports[12]
    • Baseball
    • Softball
    • volleyball
    • Gymnastics
    • Swimming

Differential Diagnosis

Differential Diagnosis Shoulder Pain

Clinical Features

Left arm Popeye deformity
Demonstration of the uppercut test[13]

History

  • Onset is frequently insidious in nature[14]
  • Patients may endorse a history of trauma, although this is less common
  • Will complain of pain over the anterior shoulder usually around the bicipital groove
    • Throbbing and aching
    • Worse with overhead activity
  • In patients with instability, they may endorse popping or snapping

Physical: Physical Exam Shoulder

  • Popeye Deformity: ruptured biceps tendon causes distal migration of muscle belly
  • The most reliable exam finding is point tenderness over the bicipital groove
  • The clinician should also evaluate the rotator cuff, labrum, scapular motion and range of motion
  • Given the high frequency of concomitant pathology, a comprehensive shoulder examination is essential

Special Tests

  • Speeds Test: Arm flexed forward to 90°, supinated and patient flexes against resistance
    • 50-63% sensitivity, 58-67% specificity[15][16]
  • Yergasons Test: Elbow flexed to 90°, forearm is pronated, attempt to supinate
    • 32% sensitivity, 78% specificity[16]
  • Passive Biceps Subluxation Test: extremes in range of motion to reproduce sensation of instability
  • Uppercut Test: Patient performs an uppercut maneuver against resistance
    • 88% sensitive, 94% specific when combined with bicipital groove tenderness to palpation[17]
  • Lift Off Test: Hand behind back, push off against examiner
  • Ludington Test: Place hands on top of head, flex biceps, look for 'Popeye' deformity
  • Backward Traction Test:

Evaluation

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Arm MRI: Tear of Long Head of Biceps Tendon
Short axis view of biceps tendon sheath with peritendinous fluid. This can be pathologic. In this case, there is a needle in plane performing a corticosteroid injection
This axial fat-suppressed proton density-weighted image through the bicipital groove demonstrates focally increased signal involving the superiorly-most inserting subscapularis tendon (arrowhead) with a flattened and medially subluxed long head of the biceps tendon (blue arrow).[18]
A case of tenosynovitis involving the long head of biceps tendon. Observe the inhomogeneous tendon and the thickened tendon sheath. The color Doppler image on the right shows evidence of increased vascularity due to inflammation. You may also use power Doppler if available to demonstrate enhanced blood flow in the affected region[19]

Radiographs

  • Start with Standard Radiographs Shoulder
  • Typically normal
  • May reveal acromial spurring or hooking
  • Consider
    • Bicipital groove view: allows for evaluation of groove[20]
    • Fisk view: allows for evaluation of bicipital groove

MRI

  • Gold standard for evaluation biceps and bicipital groove
  • Characteristic findings
    • Tendinosis
    • Partial tears
    • Edema
  • Standard non-contrast MRI
    • Sensitivity: 77.9%, specificity: 93.7% for detecting long head of biceps tendon (LHBT) pathology[21]
    • The most sensitive single finding is signal intensity alteration in the parasagittal view
    • For tear detection specifically, conventional MRI shows sensitivity of 71-83% and specificity of 73-75%[22]
  • Novel biceps-radial MRI sequences
    • Acquired in radial planes perpendicular to the LHBT demonstrating superior diagnostic accuracy
    • This technique shows excellent agreement with arthroscopy for LHBT tears, LHBT instability, and pulley lesions[23]
  • MR Arthrography
    • Can improve delineation of intra-articular component of tendon
    • For tear detection, no significant difference exists between unenhanced MRI and direct MR arthrography

CT

  • Not routinely obtained to evaluate LHBT
  • CT arthrography demonstrates higher sensitivity (71.43%) and specificity (100%) compared to MRI[24]

Ultrasound

  • General[25]
    • Can be used to diagnose rupture, subluxation, dislocation or peritendinous edema
    • Limited sensitivity for detecting partial-thickness tears and intra-articular patholog
  • Characteristic findings:
    • Tendon thickening
    • Tenosynovitis/hypertrophy of the synovial sheath
    • Fluid surrounding the tendon in the groove
  • Diagnostic accuracy
    • Complete ruptures: sensitivity 88-100%, specificity 71-98%[26]
    • Subluxation or dislocation: sensitivity 100%, specificity 96%[27]
    • Partial thickness tears: sensitivity 17-71%, specificity 71-100%
    • Tendinopathy/ tendinosis: sensitivity 50-63%, specificity 58-100%
  • Shear wave elastography
    • Shows promise for predicting intra-articular LHBT lesions
    • Difference in shear modulus between affected and unaffected sides demonstrating strong correlation with arthroscopic classification of lesions[28]

Classification

  • Not applicable

Management

Proximal biceps tendon tenodesis
Probe position for short axis (A) and long axis (B) Biceps Tendon Sheath Injection[29]

Nonoperative

  • First line treatment for
    • Tendinitis, tendinosis
    • Mild instability
  • Initial therapy

Procedures

Operative

  • Indications
    • Refractory to conservative management (usually at least 3 months)
    • Significant fraying, tearing, hypertrophy
    • Complete or large partial thickness tears (>25-50%)
    • Persistent subluxation
    • Patients with high physical demands
  • Technique
    • Tenotomy
    • Tenodesis
    • SLAP repair

Rehab and Return to Play

Biceps tendon rehab exercises
Biceps tendon strengthening exercises

Rehabilitation

  • Tenotomy Post-op[31]
    • Weeks 1-2: Sling
    • Weeks 2-4: Active ROM, discontinue sling
    • Weeks 4-6: Strengthening
  • Tenodesis Post-op
    • Weeks 1-4: Sling, with passive range of motion, grip strengthening
    • Weeks 5-6: full active and passive ROM, active flexion, supination
  • Early rehabilitation phase[32]
    • Progressive range of motion, strengthening exercises
    • Low-load exercises the generate minimal biceps EMG activity
    • Target scapular stabilizers while minimizing biceps stress
  • Intermediate phase
    • Progress to moderate-load exercises (20-50%)
    • Exercises targeting the trapezius, internal rotation movements
  • Advanced phase[12]
    • Incorporate moderate- to high-load, sport-specific exercises to prepare for return to play
    • Biceps loading can be increased through sagittal plane elevation, elbow flexion with supination without upper arm support, biceps contraction from an elongated position, or high-velocity explosive exercises

Rehab Programs PDF

Return to Play

  • General RTP criteria
    • Restoration of full, pain-free range of motion
    • Near-symmetrical strength
    • Successful completion of sport-specific functional testing
  • Essential RTP criteria
    • Anatomical and physiological healing
    • Functional restoration of the injured part
    • Sport-specific conditioning and performance capability
    • Psychological readiness and confidence
  • RTP timeline
    • Light work 3-4 weeks post op
    • Unrestricted activity 3-4 months

Prognosis and Complications

Prognosis

  • General[14]
    • Generally have a favorable prognosis with both nonoperative and surgical management
    • Outcomes vary based on the specific pathology, treatment approach, and patient activity level
    • Most patients achieve reliable pain relief and restoration of function for activities of daily living,
    • Return to overhead sports can be unpredictable
  • Nonoperative
    • Effective for mild to moderate biceps tendinopathy[33]
  • Surgical management
    • Both tenotomy and tenodesis provide effective pain relief with low complication rates
  • RTP
    • Return to play in overhead athletes remains unpredictable

Complications

  • Cosmetic "popeye" deformity
  • Muscle pain, spasms
  • Following tenotomy
    • Popeye deformity
    • Cramping/ soreness in biceps muscle
    • Strength deficits in elbow flexion, supination
  • Following Tenodesis
    • Broader range of potential complications
    • Infection, stiffness, hematoma, neurovascular injury

See Also

Internal

References

  1. ↑ Patton, W. Christopher, and George M. McCluskey III. "Biceps tendinitis and subluxation." Clinics in sports medicine 20.3 (2001): 505-529.
  2. ↑ ROBERT, PROPER. "Jan Stephan van Calcar–Portraits of the Artist." Journal of the History of Medicine and Allied Sciences 14.10 (1959): 519-522.
  3. ↑ Beall DP, Williamson EE, Ly JQ, Adkins MC, Emery RL, Jones TP, Rowland CM. Association of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR Am J Roentgenol. 2003 Mar;180(3):633-9.
  4. ↑ Lafosse L, Reiland Y, Baier GP, et al. Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations. Arthroscopy. 2007;23:73–80.
  5. ↑ Kayaalp, M. Enes, and Yigit Umur Cirdi. "“Popeye deformity” associated with proximal biceps tendon rupture." Cmaj 194.10 (2022): E386-E386.
  6. ↑ van Deurzen, Derek FP, et al. "Clinical relevance of the anatomy of the long head bicipital groove, an evidence‐based review." Clinical Anatomy 34.2 (2021): 199-208.
  7. ↑ Favorito PJ, Harding WG, Heidt RS. Complete arthroscopic examination of the long head of the biceps tendon. Arthroscopy. 2001;17:430–432.
  8. ↑ Vestermark, George L., et al. "The prevalence of rotator cuff pathology in the setting of acute proximal biceps tendon rupture." Journal of Shoulder and Elbow Surgery 27.7 (2018): 1258-1262.
  9. ↑ Miller, Kyle E., and Daniel J. Solomon. "Paralabral rupture of the proximal biceps tendon from light weightlifting." Military medicine 173.12 (2008): 1238-1240.
  10. ↑ Cheng, Nicholas Mauwei, et al. "The arterial supply of the long head of biceps tendon: anatomical study with implications for tendon rupture." Clinical Anatomy 23.6 (2010): 683-692.
  11. ↑ Churgay, Catherine A. "Diagnosis and treatment of biceps tendinitis and tendinosis." American family physician 80.5 (2009): 470-476.
  12. ↑ 12.0 12.1 Borms D, Ackerman I, Smets P, Van den Berge G, Cools AM. Biceps Disorder Rehabilitation for the Athlete: A Continuum of Moderate- to High-Load Exercises. Am J Sports Med. 2017 Mar;45(3):642-650.
  13. ↑ King, Joseph J., and Thomas W. Wright. "Physical examination of the shoulder." The Journal of Hand Surgery 39.10 (2014): 2103-2112.
  14. ↑ 14.0 14.1 Chalmers, Peter N., and Nikhil N. Verma. "Proximal biceps in overhead athletes." Clinics in Sports Medicine 35.1 (2016): 163-179.
  15. ↑ Gill, Harpreet S., et al. "Physical examination for partial tears of the biceps tendon." The American journal of sports medicine 35.8 (2007): 1334-1340.
  16. ↑ 16.0 16.1 Chen, Hung-Sheng, et al. "A comparison of physical examinations with musculoskeletal ultrasound in the diagnosis of biceps long head tendinitis." Ultrasound in medicine & biology 37.9 (2011): 1392-1398.
  17. ↑ Rosas, Samuel, et al. "A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps." Journal of shoulder and elbow surgery 26.8 (2017): 1484-1492.
  18. ↑ Image courtesy of radsource.us
  19. ↑ Image courtesy of pocus.org
  20. ↑ Cone RO, Danzig L, Resnick D, et al. The bicipital groove: radiographic, anatomic, and pathologic study. AJR Am J Roentgenol. 1983;41:781–788.
  21. ↑ Kim, Jung Youn, Sung-Min Rhee, and Yong Girl Rhee. "Accuracy of MRI in diagnosing intra-articular pathology of the long head of the biceps tendon: results with a large cohort of patients." BMC Musculoskeletal Disorders 20.1 (2019): 270.
  22. ↑ Tadros, Anthony S., et al. "Long head of the biceps brachii tendon: unenhanced MRI versus direct MR arthrography." Skeletal radiology 44.9 (2015): 1263-1272.
  23. ↑ Takeshima, Minoru, et al. "Efficacy of biceps-radial-slice magnetic resonance images for the diagnosis of biceps and pulley lesions." Journal of Shoulder and Elbow Surgery 32.12 (2023): 2436-2444.
  24. ↑ Nourissat, Geoffroy, et al. "Contribution of MRI and CT arthrography to the diagnosis of intra-articular tendinopathy of the long head of the biceps." Orthopaedics & Traumatology: Surgery & Research 100.8 (2014): S391-S394.
  25. ↑ Courage, Olivier, Floris van Rooij, and Mo Saffarini. "Ultrasound is more reliable than clinical tests to both confirm and rule out pathologies of the long head of the biceps: a systematic review and meta-analysis." Knee Surgery, Sports Traumatology, Arthroscopy 31.2 (2023): 662-671.
  26. ↑ Skendzel, Jack G., et al. "Long head of biceps brachii tendon evaluation: accuracy of preoperative ultrasound." American Journal of Roentgenology 197.4 (2011): 942-948.
  27. ↑ Armstrong, April, et al. "The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology." Journal of shoulder and elbow surgery 15.1 (2006): 7-11.
  28. ↑ Zhang, Huaguo, et al. "Ultrasound shear wave elastography-derived tissue stiffness predicts the lesions of the intra-articular long head of the biceps tendon." Journal of Shoulder and Elbow Surgery (2025).
  29. ↑ Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  30. ↑ Hashiuchi, Tomohisa, et al. "Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial." Journal of shoulder and elbow surgery 20.7 (2011): 1069-1073.
  31. ↑ Varacallo, Matthew, and Scott D. Mair. "Proximal Biceps Tendinitis and Tendinopathy." StatPearls [Internet]. StatPearls Publishing, 2019.
  32. ↑ Ryu, Jessica HJ, and Robert A. Pedowitz. "Rehabilitation of biceps tendon disorders in athletes." Clinics in sports medicine 29.2 (2010): 229-246.
  33. ↑ Nho, Shane J., et al. "Long head of the biceps tendinopathy: diagnosis and management." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 18.11 (2010): 645-656.
Created by:
John Kiel on 17 June 2019 19:17:28
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30 December 2025 17:12:08
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