Biceps tendon pain

Pain in the area of the biceps tendon at the shoulder joint often manifests itself in the anterior, shoulder-near area of the upper arm. Different diseases in the area of the biceps tendon can lead to problems.

The biceps muscle is a large, powerful muscle of the upper arm that consists of two heads (caput longum=long biceps tendon and caput breve=short biceps tendon). Both the long biceps tendon (LBS) and the short biceps tend on originate at the scapula (shoulder blade). The LBS originates at the upper edge of the glenoid cavity of the shoulder joint and passes over the head of the upper arm (humerus) in a groove (sulcus intertubercularis). Reinforcing ligaments ensure that the LBS is redirected and held along its path in this sulcus (pulley system). The short biceps tendon originates at a bony prominence (processus coracoideus) of the scapula. In the upper third of the upper arm, both parts of the tendon unite to form the large, powerful biceps muscle, which then attaches with a tendon to the radius of the forearm.

The biceps muscle is responsible for various movements in both the shoulder joint and the elbow joint. In the shoulder joint, it assists in lifting the arm forward (anteversion), rotating the pinned arm inward (internal rotation), and moving the extended arm away from the body (abduction). In the elbow joint, the biceps muscle is the main flexor (flexion) and allows the hand to rotate outward (supination) when the elbow is bent at 90°. In addition to these movement functions, the LBS has the function of stabilizing the humeral head in the socket.

Due to the anatomical peculiarities of the LBS, this tendon, in contrast to the short biceps tendon, is most frequently affected by diseases, e.g. injuries, inflammations or instability. The lesion can be localized in the shoulder joint, at the upper edge of the glenoid cavity(SLAP region) or in the course of the tendon in the shoulder joint or at the transition of the bony groove at the humeral head(pulley).

Overloading of the tendon after increased stress (weight training, rowing) can trigger inflammatory pain(biceps tendinitis) at the tendon gliding tissue.

In a proximal biceps tendon rupture, the LBS is affected in the region of the shoulder joint (near the body, proximal) in the course of the tendon. A tear of the distal biceps tendon in the region of the elbow (distal to the body) or a tear of the short biceps tendon (proximal to the body) is very rare. However, a tear/tear can also occur directly at the attachment of the tendon to the glenoid in the region of the joint lip (labrum)(SLAP lesion). Instability of the LBS at the junction with the humeral head due to resulting damage to the pulley ligaments of the muscle tendons is called a Pulley lesion.

Signs of a biceps tendon problem may include:

• Sudden pain in the front area of the upper arm
• Pain during certain movements (e.g., sports, overhead activities)
• Rest pain
• Loss of strength, feeling of weakness
• Bruise, swelling
• Popeye sign (sinking of the muscle belly)

Symptoms of biceps tendon problems vary depending on the location and cause of the damage.

When the LBS is torn, there is a sudden onset of pain in the anterior upper arm accompanied by tenderness in this area. Certain movements, such as raising the arm or bending and outward rotation in the elbow joint, are only possible with pain. These movements are also accompanied by a lack of strength. Bleeding into the tissue is clearly visible in the case of a tear of the LBS.

A typical sign of a tear of the LBS is the Popeye sign: When tensing the M. Biceps, a sinking of the muscle belly towards the elbow becomes visible.

Inflammation of the tendon due to overuse often causes pain at rest or even at night.

Causes of changes in the biceps tendon include:

• Overloaded
• Age-related (degenerative)
• Accidental (traumatic)

Overloading the tendon after increased stress (e.g. weight training, rowing) can lead to painful inflammation of the tendon tissue(biceps tendinitis).

Athletes, especially in throwing sports (volleyball, javelin throw), are predestined for LBS problems due to degenerative tearing of the tendon.

A tear of the LBS in older patients is usually caused by age-related wear and tear in the shoulder joint, such as a long-standing impingement syndrome or shoulder arthrosis.

In younger patients, a tear of the LBS is usually caused by an accident or by excessive stress during sports.

If the LBS tears at its origin at the upper edge of the glenoid cavity and the joint lip (labrum) is detached as well, this is called a SLAP lesion. A SLAP les ion can be caused by an acute trauma, such as a pull on the prestressed biceps tendon, by a fall on the shoulder, by the head of the humerus popping out of the socket (luxation) or also during contact sports (e.g. handball).

Since imaging diagnostics often do not show clear changes in the biceps tendon, many years of medical experience are indispensable for making a diagnosis. Our experienced shoulder specialists will interview you in detail regarding your exact complaints. Among other things, they will discuss the triggers, duration and severity of your complaints.

Furthermore, a thorough, functional examination is performed in which both the ability to move and the strength in the shoulder and elbow joints are checked. The position of the muscle belly(Popeye sign) is also checked.

If the suspicion of a biceps tendon tear is confirmed, imaging diagnostics are performed following the functional examination. This may involve an ultrasound, an X-ray and/or an MRI examination. In an ultrasound examination, for example, fluid around the tendon tissue of the LBS (inflammation, hemorrhage) can be detected. The location of the LBS in the sulcus of the humeral head or any dislocation of the tendon from the sulcus can also be assessed. An x-ray is used to rule out a bony fracture. Magnetic resonance imaging (MRI) can be used to detect involvement of the rotator cuff (shoulder joint stabilizing muscles), a tear in the tendon in the area of the joint lip (labrum) = SLAP lesion or changes in the pulley system that holds the tendon.

Depending on the cause of the complaints, various therapy options with a conservative or surgical treatment approach can be considered.

The choice of therapy is very individual and depends on various factors, such as the age of the patient or the degree of sporting activity in everyday life. Our experienced physicians will provide you with competent advice in this regard. In the case of a Popeye's sign, the cosmetic aspect is in the foreground.

Conservative therapy:

The following conservative therapies are available:

• Rest, cooling (PECH rule)
• Drug therapy: painkillers, injections (cortisone, platelet-rich plasma)
• Physiotherapy
• Physical therapy: electro therapy (TENS)
• Shock wave therapy

The so-called PECH rule (rest, ice, compression, elevation) is usually used directly after accidents or sports injuries. The affected part of the body, in this case the upper arm, should be immobilized and rested immediately. In addition, cooling should be applied to reduce swelling and decrease pain. Compression of the body part should reduce any bleeding and elevation should facilitate the return flow of blood.

Painkillers from the group of non-steroidal anti-inflammatory drugs (NSAIDs) can be used to reduce pain. If this is not sufficient, local injections of analgesic and anti-inflammatory agents can be given (e.g. cortisone, platelet-rich plasma, Traumeel S®).

Moving forward, targeted physical therapy treatment should be started to strengthen the rotator cuff muscles to achieve stabilization of the shoulder joint, resulting in relief of the LBS.

Tendonitis (biceps tendinitis) is always treated conservatively at first. Here, symptomatic pain therapy (e.g., with NSAIDs) comes into play. In addition, infiltration treatment can be carried out, e.g. with a local corticosteroid, with platelet-rich plasma or also with a naturopathic homeopathic substance (Traumeel S®). Shock wave therapy can also be successful by stimulating the metabolism specifically in the tendon area.

In the case of a rupture of the LBS, both conservative therapy and surgery can be used. Our shoulder specialists at the Orthozentrum will be happy to advise you further in this regard.

Operation:

If conservative treatment of biceps tendonitis (tendinitis) is unsuccessful, surgical intervention can lead to success. In this case, the LBS is cut (tenotomy) and, if necessary, reattached during the operation (tenodesis). This operation is usually performed arthroscopically.

In the case of a tear or avulsion of the LBS at the upper edge of the glenoid cavity with tearing of the glenoid lip(SLAP lesion), surgery is usually performed by means of arthroscopy. During this procedure, the surgeon can use a camera with a light source to view the extent of the biceps tendon injury and, if necessary, refix the tendon using suture anchors in the area of the glenoid cavity together with the detached labral parts. Alternatively, the LBS can be cut during surgery (tenotomy), which can then be reattached elsewhere bony or soft tissue (tenodesis) during the course of surgery.

OP at a glance:

• Operation time: 60 min.
• Anesthesia: General anesthesia
• Clinic stay: inpatient
• Able to work: depending on the activity between 4-8 weeks
• Return to sports (RTS): 10-12 weeks

In the first weeks after surgery, the biceps muscle should be spared. In the further course, targeted physiotherapeutic treatment should be started. After reattachment of the tendon, rest is required for 6 weeks to allow the tendon to heal. In particular, the biceps muscle should not be subjected to weight-bearing or active rotational movements in the forearm against resistance.