Biceps tendonitis and pathologies at the shoulder

Biceps pathologies at the shoulder:

Biceps tendonitis is one of the most frequent pathologies of the shoulder affecting the rotator cuff.
Biceps tendonitis can be isolated or, more frequently, associated with other shoulder pathologies: instability lesion (shoulder dislocation) with labral lesion, subacromial impingement syndrome and supraspinatus tendonitis, cuff tear with subscapular muscle tear, shoulder osteoarthritis (glenohumeral osteoarthritis)

There are various biceps pathologies:

- Isolated inflammatory tendonitis, which is synovitis located around the biceps' insertion; it can result from injury, be associated with subacromial impingement, or, more frequently, occur spontaneously.

- Biceps tendinopathy with dislocation, the long biceps has moved out of its groove, is unstable, causes intense shoulder pain, and damages the subscapularis muscle's insertion tendon

- SLAP lesion: biceps lesion that extends to the superior labrum, isolated or associated with shoulder instability (recurrent dislocation)

- Spontaneous tear of long head of biceps, causing a noticeable increase in the biceps’ volume at the upper arm, known as "Popeye sign". In the presence of this tear, the possibility of an associated tear of the rotator cuff must always be investigated.

Video of arthroscopic treatment of long head of biceps tendonitis:

Arthroscopic shoulder surgery video showing an operation for biceps tendonitis / Toulouse specialist

Biceps brachii anatomy:

The biceps muscle is located on the anterior side (front) of the upper arm. The biceps descends from the shoulder blade, above the shoulder joint, to the radius, below the elbow joint.
At its distal extremity (below the elbow), it is attached by a single tendon where traumatic ruptures can occur: tear of the distal biceps at the elbow.

Biceps anatomy: 2 tendons at the shoulder, 1 tendon at the elbowDislocation of biceps with subscapularis tear, Toulouse

At its proximal (superior) extremity, the biceps muscle is attached by two tendons, the short head, directly attached to the coracoid process (outside the joint), and the long head that along a humeral groove (bicipital groove) and then through the joint to insert at the upper part of the glenoid. This long head tendon is the cause of many cases of shoulder pain.

Treatment of biceps pathologies at the shoulder:

The treatment of associated pathologies is of course essential:

- repair of the cuff in case associated rotator cuff tear lesions are found

- shoulder stabilisation surgery if instability due to recurring dislocation of the shoulder is found

- treatment of subacromial impingement by bursectomy-acromioplasty if associated supraspinatus tendonitis is found

In isolated biceps tendonitis, the initial treatment is medical and can combine numerous therapies: rehabilitation, slow-release corticosteroid injections in the intra-articular space, mesotherapy along the bicipital groove.

Treatment of isolated tears of the long head is not surgical, even with a Popeye sign at the upper arm; often it is the form of tendonitis that resolves within weeks.

When the response to medical treatment is insufficient, arthroscopic shoulder surgery can be considered.

Inflamation of biceps at its insertion site at the shoulder, arthroscopic view, ToulouseInflammation of biceps in its groove, Toulouse

This surgery, which is specific to biceps pathologies, is always done arthroscopically and always involves severing the long head at its glenoid insertion site (biceps tenotomy) and attaching the tendon to the humeral groove (biceps tenodesis). Surgeons refer to this as Long head biceps tenotomy-tenodesis.

Arthroscopic exploration of the shoulder joint makes it possible to survey perfectly the insertion site of the long head of the biceps, to assess any possible associated lesions of the superior labrum (SLAP lesion) as well as its position and its stability at the humeral groove.

Arthroscopic view of biceps dislocation after a complete tear of the subscapularisView of SLAP lesion before biceps tenotomy

The simplest method for fixation (biceps tenodesis) is a T-shaped biceps tenotomy allowing the biceps to naturally attach itself to the top of the humeral gutter; this is called the parachute technique. This is an extremely reliable technique that does not require any screw or implant and thus minimizes peri-operative risks.
Another technique consists in attaching the biceps' tendon at the groove using an anchor. The same type of anchor is used as for rotator cuff repair.

Arthroscopic view of bicipital grooveArthroscopic tenodesis of biceps at shoulder using anchors, Toulouse

 

Fixation of the long head of the biceps is also possible at the lower part of the groove, by means of an intra-osseous tunnel and interference screw.  This technique provides solidity but is likely to cause persisting pain around the screw to which the biceps is attached.
Lastly, the biceps tendon can be directly inserted in the bone at the lower part of the groove (keyhole procedure); this technique provides efficient fixation without having to use a screw or an implant. However this tenodesis technique requires bone surgery which makes it dependent on the uncertainty of bone healing...

Whatever the technique used, biceps tenodesis (fixation) is likely to leave a biceps that is a little bigger at the upper arm, which is known as Popeye sign, in reference to the famous cartoon character. Tenotomy-tenodesis of the biceps long head is however extremely efficacious to reduce shoulder pain.
Shoulder recuperation and rehabilitation after arthroscopic treatment of isolated biceps tendonitis

 

Shoulder recuperation and rehabilitation after arthroscopic treatment of isolated biceps tendonitis

The following information applies to recovery in isolated forms without associated rotator cuff tear or subacromial impingement.
Non-strict shoulder immobilization will be suggested for 1 to 2 weeks; it can be stopped on request depending on how much pain is felt. Specialized shoulder rehabilitation must be started immediately after surgery to prevent stiffening. After surgery, most daily activities can resume after 2 to 3 weeks and forceful activities after 2 to 3 months. Any flexion of the elbow under constraint must be avoided for 2 months. Driving often resumes toward the end of the third postoperative week. Shoulder recovery and maximum recuperation spread over 3 to 4 months.

Tendonitis of the biceps at the shoulder, live without the pain

Sick leave obviously depends on the occupation: one week at least for office work and 2 months for occupations that are more demanding on the shoulder