Patients are often confused when I inform them that the biceps (long head of the biceps) is to blame for their shoulder pain. Most think of their biceps as the “Popeye” muscle at the mid portion of the upper arm.
To understand why the biceps can play a role in shoulder pain, we need to understand a little anatomy. The long head of the biceps takes a right-hand turn as it dives into the shoulder joint, attaching at the labrum, which is a cartilage rim around the cup, or the glenoid, of the ball and cup shoulder joint.
The reason the long head is susceptible to injury is because it is vulnerable in its journey. There are two parts to the biceps tendon - the long and the short head. The short head does not tear often and isn’t a part of the actual shoulder joint. Because of the short head, most sedentary people can still use their biceps even if the long head is completely torn - though cosmetically there may be an asymmetry in the appearance of the biceps. It can appear a little more “bulgy” and orthopaedic surgeons actually call this a “Popeye deformity”.
Sometimes the long head of the biceps can be torn traumatically (by falling, over stretching the arm, or with sudden heavy lifting). In younger patients, the injury tends to be traumatic, but as patients get older, there can be tears because the tendon has started to degenerate. Often, these also go hand in hand with rotator cuff injuries as well.
The probability of a tendon tear increases with several factors: age, overuse, sporting activities, smoking. Older people are at a higher risk because of years of wear and tear. If you have a job that requires heavy overhead lifting, it can put a lot stress on your tendons. Sports are the third reason for acute injury or wear and tear over time. Smoking can also affect the nutrition in your tendons and thus their ability to heal.
Symptoms include sharp upper arm or shoulder pain, an audible “pop”, muscle cramps at the biceps, bruising from the elbow to the upper arm, weakness in the elbow or shoulder, difficulty in rotating your palm up or down, and a “Popeye deformity” as described above. Interestingly, those that had some pain leading up to the tear (because they already had some degeneration in the tendon, or partial tearing), will often get relief once the tendon tear is completed! Complete tears are easier to diagnose because of the “Popeye deformity”. Partial tears are harder to diagnose because the tear is less obvious.
Other conditions that can go along with a tendon tear are: rotator cuff injuries, tendinitis, and impingement.
The treatment for these tears, either partial or complete, may be surgical or non-surgical. Non-surgical treatments may include ice, NSAIDs such as ibuprofen, physical therapy, rest and activity modification.
Patients are often surprised that when they are a candidate for surgery, that it is not actually a repair of the tendon. Rather, we take the torn tendon and create a new attachment point on the humerus close to the shoulder. There are several techniques of doing so that are effective, some with hardware such as anchors, some without.
If there is a painful partial tear, and the sedentary patient hasn’t done well with non-surgical treatment, we will sometimes perform what’s called a tenotomy, where we release the tendon and just let it heal where it lies once released. If you think about it - this is why some people who have been suffering from a painful partial tear for a while suddenly get SO much better once it pops on its own! The body has done what the surgeon would have, had it come to that!
Just letting the biceps heal where it is after tearing, or performing the tenotomy may be fine for those that don’t do much heavy repetitive lifting, and don’t mind a little asymmetry from side to side. But, for more active individuals, a biceps tenodesis may be preferred.
If you feel you may have an injury to the biceps tendon at the shoulder, discuss your symptoms with your primary care physician or orthopaedic surgeon