As its name suggests, the biceps muscle consists of two muscle heads (Latin “bi” meaning two). It has two tendons, a short and a long head, which originate from different points on the shoulder blade. The long head of the biceps tendon originates from the upper rim of the glenoid, passes through a groove in the upper arm bone (bicipital groove), and attaches to the radius in the forearm.

The biceps acts as a flexor of the arm and is the primary supinator of the forearm when the elbow is bent, for example when tightening a screw.

The long head of the biceps tendon can be affected by various conditions.

• SLAP Lesion (Tear at the Tendon Origin)

• Tendinopathy/Tendinitis (Inflammation of the Tendon)

• Tendon Instability (Medial Subluxation of the Tendon)

• Long Head of the Biceps Tendon Tear (Proximal or Distal)

If the long head of the biceps tendon is damaged, patients typically experience pain in the front of the shoulder. Activities involving the arm away from the body and overhead tasks with weights are often painful, such as reaching from the front passenger seat of a car to grab a bag from the back seat or using heavy tools overhead. Range of motion and strength are usually not impaired.

Fluid collections associated with inflammation are easily detected on ultrasound, as there is normally no fluid surrounding the biceps tendon. Both fluid accumulation and tendon instability can be clearly visualized, particularly during a dynamic ultrasound examination. The patient is asked to perform specific movements during the examination.

This examination can determine how the biceps tendon moves, whether it remains stable, or whether it slips out of the bicipital groove.

An MR arthrogram (arthro-MRI) uses contrast medium to show the position of the tendon and determine whether it is subluxated or in its normal position. The examination is performed with the shoulder at rest. If the tendon is subluxated medially, this can be identified on the images. This diagnostic procedure is also used to assess SLAP lesions. Contrast medium is injected into the joint to determine whether it enters the tear or partial tear, indicating a gap in the tissue.

Where inflammation or irritation has developed, medication can help relieve symptoms. High-dose NSAIDs are used to reduce inflammation. These medications may be prescribed for 10 to 14 days. Patients are usually also given medication to protect the stomach.

If this treatment is not effective, a corticosteroid injection may be considered. Corticosteroids have the advantage of reducing inflammation and can help break the cycle of pain, friction, and swelling.

If non-surgical treatment is unsuccessful, surgery can be performed using a minimally invasive arthroscopic procedure.

In patients who have sustained a SLAP lesion as a result of trauma rather than degeneration or wear and tear, surgical repair and fixation may be considered.

Once symptoms such as instability or irritation become chronic and conservative treatment has not been effective, the tendon can be surgically released.

There are two options for performing this procedure. Tenotomy refers to cutting the tendon without reattaching it. Although the long head of the biceps tendon is released, muscle function is maintained by the short head of the biceps. This is comparable, for example, to an appendectomy. Although the appendix is removed, the function of the intestine is not affected. The other option is called tenodesis. In this procedure, the tendon is released and then reattached at another location on the upper arm bone.

Neither option has clear advantages over the other. In terms of function, both procedures are comparable. In some cases following a tenotomy, a bulge in the muscle may develop that is more pronounced than on the unaffected side. This is known as the “Popeye sign,” referring to the characteristic bulge in the upper arm.

If a spontaneous rupture of the long head of the biceps tendon occurs, the tendon may either be left untreated or a biceps tenodesis may be considered.

The biceps tendon can also partially or completely tear at its distal attachment near the forearm. In such cases, the tendon is usually reattached to its insertion point to restore strength for forearm rotation and flexion.