Anatomy:
The Biceps is an upper arm muscle that acts across the shoulder and elbow joints. At the elbow, it helps to bend the joint. At the shoulder, its function is more complex and incompletely understood. So the main function is to flex (bend) the elbow and to supinate the forearm ( supination is the screwing motion of the forearm)
The biceps has two tendons around the shoulder: the long tendon passes inside the joint via a groove in the ball and attaches to the upper end of the shoulder socket, and the short tendon passes outside the joint to an adjacent bony outgrowth (coracoid).
The long tendon of the biceps is the problematic entity in shoulder pain.It slides in the groove on the head of the humerus in the joint and if the tendon is swollen and inflamed it becomes very painful, and shoulder movements become painful and restricted with accompanying night pain.
 |
 |
Arthroscopic view (left) and diagrammatic representation (right) of the
Biceps tendon passing through the groove.
Diseases/disorders of the tendon:
1. Inflammation of the tendon: Bicipital tendonitis. The Long tendon of the biceps slides in a groove on the shoulder ball during movements of the arm. Friction between the surfaces result in “soreness” of the tendon, called “Tendonitis”. Within the shoulder, the tendon appears “Red” with tiny blood vessels on its surface. Untreated, the tendonitis progresses to fraying and tears.
Bicipital tendonitis
2. Fraying/ partial tearing of the tendon. Persistence of friction on an inflamed tendon leads to this condition. The tendon appears frayed, which implies separation of individual fibres.
Frayed/torn biceps tendon.
3. Complete tears/ Rupture of the tendon. Persistence of friction on a frayed out tendon leads to this condition. The tendon cannot be seen from within the joint as it slips into the groove on the ball. The resultant slack on the muscle leads to a “Popeye” like muscle deformity.(see below)
Torn biceps tendon seen inside the joint.
4. Tears around the tendon attachment at the upper end of the shoulder socket (SLAP tears). These are seen in throwing athletes.
SLAP tear: separation of biceps tendon attachment from
the upper end of the shoulder socket
.The origin of the long head of the biceps can be seen to be located at the
superior edge of the glenoid. A tear of the origin (the root) of the biceps off
the glenoid is referred to as a "SLAP" lesion ("SLAP" = "Superior Labrum, Anterior to Posterior")
Diagnosis:
CLINICAL:
Biceps tendon disorders can present in different ways.
1. Pain: Pain around the front of the shoulder, arm and sometime passing down the upper limb is suggestive. The pain occurs with movements of the arm (mechanical in nature) Pressure on the groove is painful, and an injection of a local anaesthetic drug in the groove, under ultrasound control, provides relief.
2. Clicking: Partially torn tendon and SLAP tears can cause obstruction to movements of the arm and gives an unpleasant sensation of “clicking”.
3. Deformity: Complete tears of the biceps tendon can result in a “Popeye” like muscle appearance.
Acute rupture of the long head of the biceps: blue-purple discoloration and
"popeye" deformity
Chronic rupture of the long head
biceps
RADIOLOGICAL:
Xrays do not reveal biceps problems.
MRI and ultrasound are sometimes useful. Fluid around the tendon, and displacement out of the groove are some of the indicators of possible biceps pathology.
 |
 |
Arrows show an empty groove on ultrasound (left) and MRI (right).
ARTHROSCOPY:
Arthroscopy accurately shows the inflamed, frayed, or torn biceps tendon, and SLAP tears.
 |
 |
Treatment:
Conservative:
1. Avoidance of movements that cause shoulder pain.
2. Cortisone injections into the groove, under ultrasound control, to reduce inflammation. The injection under ultra-sound control is certainly the most efficient as it is very difficult to administer such an injection accurately into the groove without the ultra-sound. Such an injection is also very diagnostic as the effiect of the local anesthesia is immediate and if there is immediate pain relief it would prove the diagnosis.
The surgeon injecting the biceps groove
while watching the needle on the ultrasound
Surgical:
Arthroscopy confirms the problem and should be used to simultaneously treat the problem. The principle of surgery for this condition is the following: the long head of the biceps slides in the groove on the humeral head and if the tendon is swollen and frayed out it cannot glide freely and causes pain. The biceps tendon is detached (cut off ) from its attachment on the upper socket and does then not have to slide in the groove. If it is detached it only leads to about 15% of loss of power of flexion of the elbow adn of course the "pop-eye" deformity of the muscle. One of a few things can be done to the tendon after cutting it (referrred to as "tenotomy").
1. It can be left as a "tenotomy" and accept the slilght weakness of elbow flexion and the bulge on the front of the upper arm - usually restricted to older inactive indiviuals Although similar to a rupture, this method has been shown to provide excellent relief of pain and is ideal in patients fro whom a cosmetic deformity is not an issue. It does have the side effect of biceps cramping in certain individuals especially if they have strong biceps muscles.
2. The tendon can be fixed to the bone of the upper arm with a bone anchor or an "interference screw" ("Biceps tenodesis").
In both these cases it eliminates the sliding of the tendon and thereby removes friction. Pain relief is usually very good. In the case of option 1 (tenotomy) motion can be allowed immediately after the operation but in the case of option 2 (biceps tenodesis) motion has to be restricted to allow for healing of the tendon to the bone.
BICEPS TENODESIS:
As mentioned above the biceps tendon is cut from its origin and then fixed to the bone of the humeral head.
The operation is done arthroscopically
The tendon is cut free from its origin and fixed to the bone in the groove on the head of the
humerus
The cut tendonis fixed to the groove using
absorbable devices - the tendon
will now heal to the groove.
The cut tendon and the pepared hole in the bone......
The tendon being pushed into the hole.........
And fixed with an absorbable screw ("Biceptor" screw)
Diagrammatic view of the fixation of the tendon
with the screw
SLAP tears are repaired arthroscopically to the detached area of bone using tiny anchors. Severe tears are excised and the tendon may be transferred to the groove as described above (biceps tenodesis) .
Post-operative care:
For a simple tenotomy active and passive motion may be started as soon as pain permits ( pain is usually minimal after this athroscopic procedure)
Post-operative care after the tenodesis procedure: : The arm should be rested till the repair is firmly healed. Active contraction of the biceps (flexing the elbow) and passive stretching of the biceps (elbow extension) is avoided. Usually, three weeks of rest is sufficient if the tenodesis was done with a tenodesis screw. Thereafter, gradual passive and active exercises are begun and continued till full function is achieved.