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Long head of biceps

What is it?

You can feel your biceps muscle at the front of your arm when you bend your elbow and turn you palm towards your face.  This muscle inserts as one fused tendon into your forearm, but has two distinct tendons at its upper end.  The main tendon (short head) at the upper end inserts into the coracoid process of your shoulder blade.  This is outside of your shoulder joint and rarely causes problems.  The second, less functionally important ‘long head’ tendon, passes through the shoulder joint on its way to the top of the glenoid (the socket of the shoulder) where it inserts into bone. It is this long head that frequently contributes to pain in the shoulder and sometimes ruptures. Your biceps muscle has two functions: one is to help bend your elbow, the second is to provide twisting power in your forearm (supination) (e.g. screwdriver use).


What are the Symptoms?

Long Head of Biceps tendinopathy

Often patients report a gradual onset of pain felt at the front and inside the shoulder, which is made worse by pulling up your arm (weight training) or on twisting your forearm (e.g. screwdriver). They mat also have a painful area at the front of their shoulder

Ruptured Long Head of Biceps

A degenerate tendon can rupture causing the muscle to retract down the arm. This can alter the contour of your biceps to give a ‘Popeye Sign’.  Patients typically describe a sudden tearing and pain, sometimes with bruising tracking down their arm.  Normally however, there is then resolution of symptoms after a few weeks, often when the patient has had a previously irritable shoulder.  Occasionally active patients (e.g. manual workers) complain of cramping in their arm when doing repetitive tasks after long head of biceps rupture, 

Who gets it?

Proximal biceps tendon problems are rare in the under 40’s.  If young people do get symptoms, it may be due to incorrect sports technique, or shoulder motion problems.  ‘Cross-fit’ and other intensive strength training programmes may overload the biceps tendon and cause symptoms.  A superior labral (SLAP) tear can also affect the long head of biceps insertion.  Degenerative tendinopathy generally occurs in patients aged over 40 years, becoming common as we get older than 65 years.  Degenerate proximal biceps problems may co-exist with rotator cuff tears.

What non-surgical treatments are there?

  • Rest, activity modification, painkillers and anti-inflammatories
  • Physiotherapy
    • To optimise shoulder motion, rotator cuff control and to offload the biceps tendon
    • If isolated tendinopathy is confirmed, physiotherapy exercises are important to stimulate healing of the tendon
  • (Cortisone) Steroid Injection
    • If your symptoms persist, or are severe, an injection can settle inflammation and enable your rehabilitation
    • Often done under image guidance (ultrasound or X-ray)
    • Low risk of complications from single dose

Surgery for long head of biceps problems

A degenerate long head of biceps tendon is a potent pain generator in the shoulder. If your symptoms haven’t settled with non-operative measures, then you may require surgery. Sometimes your problem with the biceps tendon accompanies other problems in your shoulder that need surgical treatment. The biceps may also be noticeably damaged at surgery, in which case it is better to have it dealt with.

  • There are two main options for dealing with the biceps tendon
    1. Biceps tenotomy – the long head of biceps is cut at it’s origin and allowed to retract out of the shoulder joint into its groove
    2. Biceps tenodesis  - the long head of biceps is cut as above, but the tendon is re-fixed to bone lower down the humerus.  This fixation can be done using either keyhole technique or a mini open procedure (3cm wound in anterior armpit crease)
  • Pros and Cons of tenotomy 
    • No need for post-operative restrictions
    • Some patients (30%) develop a ‘Popeye sign’
    • A small percentage (usually younger higher demand patients) suffer from arm cramping with repetitive tasks
  • Pros and Cons of tenodesis
    • Preserves biceps muscle contour
    • Helps to reduce (but does not always eliminate) cramping
    • There is a small risk of complications from tenodesis procedure
      • Humerus fracture (very low risk <1%)
      • Nerve injury (very low risk <1%)
      • Failure of tenodesis to heal causing a Popeye (low risk 5%)
      • Cramping despite tenodesis (low risk 5%)

Recovery from long head of biceps surgery

  • Biceps surgery is rarely performed in isolation. Normally another procedure is performed at the same time, such as rotator cuff repair and/or subacromial decompression.
  • Biceps tenotomy in itself requires no functional restrictions after surgery
  • Tenodesis requires a sling for four weeks and no strength work for 12 weeks

Making the right choice about the best treatment for you means getting the right information. During your consultation, please do feel free to ask Mr Granville-Chapman to explain anything that you do not fully understand, and for his advice about the pros and cons of any treatment.